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TANGGAL NAMA PASIEN BPJS NAMA OBAT JUMLAH

1/1/2014 Ny Dian tramado in! "

d#$a in! 2

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'&r%o 1) 1

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m&*&' #$ 1

Ny O&y Tramado in! "

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tna'no *#%tria$on# 1

a3&a 1

'.&it 10 "

'&r%o 20 1

Pro'o-an 2

Ny Ani. D#$a in! 2

D 1

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Tramado in! "

N##d# 2" 1

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I 1) 1

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Ny Anin-r&m M&*&' 1

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Ny Anin-r&m A'am M#%#namat 1

Ny Ani. Amo$ Ta, 1

A'am M#%#namat 20

Ny :atna :#ian In! 1

Tn S&di,yo A'am M#%#namat 10

A'am Tran#$amat 00 10

5i.ro Ta, 10

:anitidin Ta, 10

Urin# ,a- 1Nn Amaia :anitidin In! 2

D; "

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Ny :&y :anitidin# ta, 10

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n##d# 2" 2

Tn T&miran :#ian in! 2

Ny Di in%&'#t ,ia'a 1

:L 4

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Ny M&dria( 5#%tri 4

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Nn Am#ia :anitidin in! 2

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:anitidin in! 2

A'am Tran#$amat in! "

B&'*otia "

no7a-in in! 2

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1/"/2014 Nn Amaia :anitidin Ta, 10

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Ny N&r& 5#%ota$im# In! "

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In%&'#t Dara( 1

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M&*&' E$ 1

ny :atna Amo$ ta, 1

a'am m#%#namat 1

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Ny:ati( M#t(y .r#dni'oon in! 2

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Ny M&dria( :L OGB 1

D 15#%tria$on# 2

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1/4/2014 Ny:ati( :L OGB 1S.&it 10** 1

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AnMario 5#%tria$on in! 2

Gantami'in in! 2

Noa-in in! 2D 1/2 NS 2

S.&it "** 4

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1/)/2014 Tn M&*(a' A'am M#%#namat 00 10

Tn Saido In%&'#t Dara( 1

:L OGB 1

I7 5at 20 1

Ny Laiat& 5i.ro Ta, 10


Ny Sri A't&ti In%&'#t Dara( 1

S&r%o 1) 1:L OGB 4

D#$a In! 2

S.&it 10 ** 1

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Tn M&a' *i.ro in% 1

?/1/2014 BON O9 5at-&t 5(romi* No 2 1

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Tn A,& Hamid I 20 1

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Tn Ari%in In%&'#t Dara( 1

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Ny Ani. Anita 5i.ro Ta, 10

:L OGB 2In%&'#t ,ia'a 1

I7 5at( 20 1

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"<?00

2<000

1<+00

+<?00

1<00

4<400

2<100

<+00

2<+00

2<400

1<+00

11<000

1<"00

2<000

1<+00



<+00

1<+00

2<000

1<"00

1<+00

1)<200

+<?004<=00

+<?00

+<100

+<?00

)00

1?<)00

)00

4<000

4<000

+<0004<000

4<000

1<+00

<+00

+<?00

4<=00

"<?00

200

1<000

+<?00

1<"00

2<400

2<400

2<100

1<"00

?<100

11<200

2<100

1<+00

2<000

2<+00

+<000

1<+00

2<000

+<1"4<)00 11<"4=<200 =<)2=<000




1/22/2014 Ny S&armi / BPJS 9 5a.to.ri 2 "0

24/01/2014 Tn S&,an& / BPJS A 5a.to.ri 2 10

Tn 9aryono / BPJS A amodi.in m- =

1/2)/2014 An Aan/ /ar#, :#ian 1

TnDamin /Um&m 6* 1) 1TnLamiran Amodi.in# 10

TOTAL



HA:GA OBAT NON BPJS PATEN

+000

2000

"00

00

10000

17000 5500 15500

HA:GA OBAT BPJS GENE:I9 AL9ES BPJS

HA:GA AL9ES U/BPJS



TANGGAL NAMA PASIEN BPJS GOLONGAN

2/1/2014 Tn Nati-or BPJS A

Ny S&ina( BPJS UMUM

Tn Si'yono

Tn Nati-or BPJS A

An N#ira BPJS 9

An N#ira BPJS 9

Tn Maran BPJS AS9ES

NyNaan- BPJS 9

N>S&ina( BPJS UMUM

TnNati-or BPJS A

Tn6#ry BPJS :SB

2/2/2014 An 6i8a BPJS BPJS

Tn Lamiran BPJS A

An Dima' BPJS JAM9ESMAS



TnNati-or BPJS A

TnDa&man BPJS BPJS

TnDa&man BPJS BPJS



Tn Si'yono

Ny S&ina( BPJS UMUM

2/"/2014 Tn Maran BPJS AS9ES

Tn 6at&r BPJS BPJS

Tn Maran BPJS AS9ES

Tn Da&man BPJS BPJS

An Airan--a BPJS UMUM

Ny 6at(&r :o(im BPJS BPJS

Tn Da&man BPJS BPJS


BPJS BPJS

Ny 6at(&r :o(im BPJS BPJS

Tn Lamiran BPJS A

Tn Si'yono BPJS AS9ES



Tn Maran BPJS AS9ES

Tn Nati-or BPJS A

2/4/2014 Andima' BPJS JAM9ESMAS

TnDa&man BPJS BPJS


Tn Maran BPJS AS9ES

Tn Si'yono BPJS AS9ES

Tn Lamiran BPJS A

Tn NAti-or BPJS A

2//2014 Sdraan UMUM

TnDa&man BPJS BPJS

NySri iyanti BPJS AS9ES



Tn H#mi BPJS UMUM

TnNati-or BPJS A

Ny6at&r BPJS BPJS

Tn H#mi BPJS UMUM

AnDima' BPJS JAM9ESMAS

TnBadoi BPJS AS9ES

NyS#ndy BPJS 9

NyN&r& A8i8a( BPJS UMUM

TnDian BPJS UMUM



AnDir-antara BPJS 9

2/+/2014 Ny S#ndi BPJS 9

Ny Sri iyanti BPJS AS9ES

NyS&marni BPJS 9

AnDir-antara BPJS 9

Ny Nini BPJS 9

NyNini BPJS 9

NyS#ri BPJS UMUM



AnDir-antara BPJS 9

TnDian BPJS UMUM

Ny6At&r BPJS BPJS

NyS&marni BPJS 9

2/=/2014 Ny Nini BPJS 9

NyLa'iy#m BPJS AS9ES

TnAndri BPJS A

Byinarti UMUM

Ny Nini BPJS 9

Ny S#y BPJS UMUM

Ny S#ndi BPJS 9

Tn Dian BPJS &mUM

Ny La'iy#m BPJS AS9ES

Tn Andri BPJS A



An Dir-antara BPJS J9

Ny S&tri'miati BPJS 9

An Dir-antara BPJS 9

Tn 6at&r BPJS BPJS

Ny Sri a(y&ni BPJS AS9ES

N> S&marni BPJS

N> Nini BPJS 9

Tn Andri BPJS A

N> Sri a(y&ni BPJS AS9ES

An Dir-antara BPJS 9

N> La'iyam BPJS AS9ES

2/)/2014 Ny S&tri'miati BPJS 9

Ny >anti UMUM

Ny S&tia( UMUM



Tn Andri ,.!' A

Ny Nini BPJS 9

Ny :ati( BPJS 9

NyP&!i A'y&ti BPJS Jam'o't#$

BPJS 9

2/10/2014 NyN&ni BPJS

Ny Nini BPJS 9

Ana%ina%i'a BPJ9S Jam'o't#$

TnPra'#tyo Hadi BPJS &mUM



TnS&adi BPJS MANDI:I

Ny Nini BPJS 9

Tn S&adi BPJS MANDI:I

An a%i BPJS AS9ESNy Sriati UMUM



Ny Nini BPJS 9

2/11/2014 An a%i BPJS AS9ES

NyNini BPJS 9

Ana%i BPJS

TnPra'#tyo Hadi BPJS Ma'in

2/12/2014 Tn Pra'#tyo BPJS JAM9ESMAS

Ny N&raINI BPJS &mUM

TnPra'#tyo Hadi BPJS JAM9ESMAS

Tn Pra'#tyo Hadi BPJS JAM9ESMAS

2/1"/2014 NyIra BPJ9 9



And(y'a BPJ9 9

AnDy'ma BPJ9 9

2/14/2014 An :a'ya BPJS 9

AnDy'ma BPJ9 9

Ny Si'ati UMUM

Ny Sri!ati UMUM

An Dy'ma BPJS 9

Sdr 6r#ddy BPJS 9

2/1+/2014 An Dy'a BPJS 9TnM&!ay#n BPJS A

Sdr6r#ddy BPJS 9

Tn M&!ayin BPJS A



An Dy'a BPJS 9

Sdr%r#ddy BPJS UMUM

2/1=/2014 Sdr6r#dy BPJS UMUM

2/1)/2014 Tn Samad BPJS A

Tn Sam#t BPJS AS9ES

AnDy'ma BPJS 9Tn Sam#t BPJS AS9ES

2/1?/2014 Tn May(#ndra BPJS A

Tn May H#ndra BPJS A

2/20/2014 Ny Nia BPJS 9

Ny Da'ima( JAM9ESMAS



Ny Titi' BPJS 9

Ny Amiia BPJS 9

TnMa(#ndra BPJS A

N>Titi'

TnMay (#ndra BPJS A

Tn May H#ndra BPJS A

Ny Da'ima( BPJS JAM9ESMAS

2/21/2014 Sdr 6r#di BPJS 9

Ny N&r Ati3o( BPJS BPJS

Sdr 6r#di BPJS 9

Ny>&nani BPJS MANDI:I



NyMariati BPJS AS9ES

Ny>&nai BPJS MANDI:I

NyMarati BPJS AS9ES

Ny Anin BPJS UMUM

2/2"/2014 Sdr Santo'o BPJS MANDI:I

Ny Marati BPJS MANDI:I

ny >&nani BPJS MANDI:I

Tn M&naar UMUM

Tn 9a'nadi UMUM

Nn M#i Diana BPJS 9



Ny Si'ati UMUM

Nn M#i BPJS 9

Sdr Santo'o BPJSMANDI:I

'D: 6r#dy BPJS 9

2/24/2014 Ny Eo BPJS 9

Ny Si'ati UMUM

TnS idi BPJS A

NyEo BPJS A



TnSidi BPJS 9

Ny D#i BPJS 9

Ny Eo BPJS 9

Tn Sadi BPJS A

Sdr Santo'o BPJS 9

Nn M#i Diana BPJS 9

Sdr 6r#dy BPJS 9

Ny Nina BPJS 9

2/2/2014 Sdr Santo'o BPJS MANDI:i

Ny Eo BPJS 9

By Ny N&r Nina BPJS 9

Tn a'i' S#tyo BPJS A

SdrSanto'o BPJS MANDI:I

ByHartati BPJS 9



NyHatati ,.!'

Tna'i' BPJS A

TnSadi3 BPJS A

NyEo BPJS 9

2/2+/2014 Ny Eo BPJS 9

Ny 9&'rini BPJS UMUM


Ny 9&'rini BPJS AS9ES



By Ny Hartati BPJS 9

By Ny N&r 9om'ia( UMUM

Ny >&'ati BPJS UMUM

Tn a'i' BPJS A

Tn Sadi BPJS A


Ny Eo BPJS 9

Ny >a'mini UMUM

2/2=/2014 Tn Anan- BPJS A



Ny Ma'ia( BPJS JAM9ESMAS

Ny Eo BPJS 9


Ny H#ni UMUM

Ny 9artini UMUM

Ny Ma'ia( BPJS JAM9ESMAS

Tn a'i' BPJS A

Tn Sadi BPJS A

An Airan--a BPJS 9

Ny Andriani UMUM

Tn Bam,an- BPJS A

2/2)/2014 TnSama.ta BPJS A



An :#(andia BPJS UMUM

An Airan--a BPJS 9

Ny L&t%ia( BPJS UMUM

Tn Anan- BPJS A

Tn Bam,an- BPJS A

Tn a'i' BPJS A

Tn Sadi BPJS A

Ny Eo BPJS 9


Ny Ma'ia( BPJS UMUM

Ny Ei BPJS 9



TOTAL

PC UMUM "42<"00

PC BPJS UMUM 1<1+<400

PC BPJS 9ELUA:GA "<=40<)00

PC BPJS ANGGOTA "<0+<?00

PC BPJS BPJS "2+<100

PC BPJS AS9ES 1<"0<400

PC BPJS JAM9ESMAS 1<01"<=00

PC BPJS MANDI:I 44<000

PC BPJS :SB +<200

PC BPJS JAMSOSTE9 1?4<000

11<+)<)00



NAMA OBAT JUMLAH

HA:GA PASIE

UMUM BPJS UMUM BPJS BPJS

M&*o-ard Syr 1 2=<"00

I7 5at( 20 1 +<?00

In%&'#t dara( 1 +<100I7 5at( 20 1 +<?00

I 5at( 22 2 1"<)00

In%&'#t ,ia'a 1 4<=00

i 5at( 20 1 +<?00

S.&it " ** 2 1<+00

S.&it ** 2 2<000

D; 1 +<000

I7 5at( 24 1 +<?00

I7 5at( 22 2 1"<)00

In%&'#t ,ia'a 1 4<=00

*#%ota$im# in! 1 <400a3&a 1 2<100

S.&it ** " "<000

S.&it " ** 4 "<200

D 1/4 NS " 2=<"00

&rin#,a- 1

a3&a 1

S.&it " ** 2

S.&it ** 2

In%&' dara( 1 +<100

D 1 +<000

I 1) 1 +<?00

6* 1+ 1 1<00

&rin#,a- 1 4<400

S.&it 10 ** 1 1<"00

S.&it ** " "<000

S.&it " ** 4 "<200

a3&a 1 2<100

*#%ota$im# in! " 1+<200

5#%tria$on# 2 10<)00

S.&it " ** 4 "<200

S.&it ** " "<000

D 1 +<000

S.&it ** 2 2<000

S.&it " ** 2 1<+00

S.&it " ** 4

S.&it ** "

In%&'#t ,ia'a 1 4<=00

Amodi.in 10 m- + +<+00

In%&'#t Bia'a 1

BPJS9ELUA:GA

BPJS ANGGOTA



5#%o 1

N##d# 2 1

A3&a 1

I 20 2 1"<)00

Intro-at 22 1 +<?00

D#$a In! " +<000

S.&it " ** = <+00

S.&it ** 2 2<000

Und#r.#d 4 1"<+00

Urin,a- 1 4<400

6* 1+ 1 1<00

A3&a 1 2<100

D 1/2 "

S.&it " ** "

S.&it ** "

*#%ota$im# in! 2

a3&a 1

D 1/2 NS 25#%tria$on# 2

S.&it 10 ** 2

S.&it " ** 4

5#%tria$on# 1 <400

S.&it " ** + 4<)00

a3&a 1 2<100

In%&'#t Bia'a 1

In%&'#t ,ia'a 1 4<=00

i 20 2 1"<)00

'.&it "** " 2<400

'.&it ** " "<000

S.&it 10 ** " "<?00

ni%#di.in 10m- 1 200

Di-o$in "

5#%tria$on# 2 10<)00

In%&'#t ,ia'a 1 4<=00

I 24 2 1"<)00

I 22 2 1"<)00

'.&it "** 1 )00

Amod.in M- 4 2<000

5#%tria$on# 1 <400

a3&a 1 2<100

P@ 0< 1 +<)00

D 1/2 NS 2

*#%ota$im# in! 2 10<)00

:L 2 12<000

:L 2 12<000

'.&it "** 2 1<+00

:L 1

6&ro'#mid# In! 2



5#%tria$on# 2

Om#.ra8o# In! 1

S.&it 10 ** "

'.&it "** 1

6&ro'#mid# In! 2

D; 1

'.&it "** 4

P@ 0< 1 +<)00

D; 2 12<000

'.&it "** " 2<400

'.&it "** 2

:anitidin in! 2 =<+00

D#$a In! 2 4<000

'.&it "** " 2<400

*#%ota$im# in! 1

D 1/2 1

a3&a 1

:anitidin in! 16&ro'#mid# In! 2

:anitidin in! 2

'.&it "** 2

'.&it ** 2

D; 1

5#%tria$on# 1

Om#.ra8o# In! 1

:L 1

:L 2 12<000


P@ 0< 1 +<)00

D; 2 12<000

6&troit 1 4+<)00

5#%tria$on 2 10<)00

:anitidin In! 2 =<+00

D#$a in! " +<000

S.&it " ** 2 1<+00

S.&it ** 2 2<000

S.&it 10 ** 2 2<+00

Na* 1 +<)00

In%&' dara( 1

I 1) 1

6* 1+ 1

Urin,a- 1

S.&it 10 ** 1

S.&it " ** )

S.&it ** "

*#%ota$im# in! "

D#$a In! 2

D 1



Amino#,an In% 1 ?"<+00

P@ 0< 1 +<)00

D 1 +<000


S.&it 10* 1 1<"00

'.&it ** 1 1<000

'.&it "** 2 1<+00

:L 2 1<200

S.&it ** 1 1<000

'.&it "** 1 )00

Amino#,an In% 1 ?"<+00

P@ 0< 1 +<)00

:L 1 +<000

5#%tria$on in! 1 <400

Om#.ra8o# In! 1 )?<)00

S.&it 10** 2 2<+00

'.&it ** 1 1<000

D 1/2NS 2*#%ota$im# in! 2

'.&it "** 2

:anitidin in! 1

In%&'#t Bia'a 1

:L "

I7 20 1

'.&it "** "

I7 1) 1 +<?00

In%&' dara( 1 +<100

:L 4 24<000

6* 1+ 1 1<00

&rin#,a- 1 4<400

'.&it "** 4 "<200

'.&it ** " "<000

*#%ota$im# in! " 1+<200

a3&a 1 2<100

S.&it 10** 1 1<"00

D 1 +<000

D#$a In! 2 4<000

N##d# 2" 1 "00

In%&' dara( 1 +<100

I7 20 1 +<?00

:L 2 12<000

'.&it "** 1 )00

5i.ro ta, 10 4<000

D 1 +<000

:L 1 +<000

5#%tria$on in! 2 10<)00

B&'*oti*a " 22<200

S.&it 10* 1 1<"00



'.&it ** 2 2<000

'.&it "** 2 1<+00

In%&'#t Bia'a 1 4<=00

:L " 1)<000

I7 22 1 +<?00

'.&it "** " 2<400

P5T 'yr 1 2<400

5i.ro ta, 10 4<000

a'am M#%#namat 20 4<000

5i.ro ta, 10

a'am M#%#namat 20

D#$a In! " +<000

S.&it 10 ** " "<?00

S.&it " ** " 2<400


in%&' ,iA'a 1 4<=00

i 20 1 +<?00

6&troit " 140<400S.&it " ** + 4<)00

S.&it ** 1 1<000

*#%ota$im# in! 2 10<)00

a3&a 2 4<200

S.&it ** " "<000

S.&it " ** " 2<400

6&troit 1 4+<)00

" ay '#an- 1 "2<+00

na* 0< 1 +<)00

'.ironoa*ton# 2<00

Amodi.in 10 m- <00

a3&a 1 2<100

In%&'#t Bia'a 1 4<=00

i 1) 1 +<?00

%*1+ 1 1<00

&rin#,a- 1 4<=00

a3&a 1 2<100

%&ro'#mid 2 4<400

'.&it 10** 1 1<"00

I7 1) 1 +<?00

In%&' dara( 1 +<100

:L 4 2<400

6* 1+ 1 1<00

&rin#,a- 1 4<=00

S.&it 10** 1 1<"00

D 1 +<000

'.&it "** " 2<400

S.&it ** " "<000

A3&a 1 2<100

*#%ota$im# in! " 1+<200



9#toroa* in! " 1?<)00

D 1/2NS 1 ?<100

D 1 +<000

:L 1 +<000

5#%tria$on in! 2 10<)00

B&'*oti*a " 22<200

S.&it 10** 1 1<"00

'.&it ** 2 2<000

'.&it "** 2 1<+00

:L 2 12<000

S.&it 10** 1 1<"00

'.&it ** 1 1<000

'.&it "** 1 )00

:L 2 12<000

D#$a In! " +<000


S.&it 10** 1 1<"00

'.&it ** 1 1<000'.&it "** 2 1<+00

6&ro'#mid# In! " +<+00

S.&it " ** 2 1<+00

S.&it ** 2 2<000

6&troit 1 4+<)00

a3&a 1 2<100

:L OGB 1

I 20 1

In%&' dara( 1

:L OGB 1 +<000

I 20 1 +<?00

In%&' dara( 1 +<100

:#ian 2 11<000

5#%tri In! 2 10<)00

a3&a 1 2<100

S.&it 10 ** 1 1<"00

N##d# 2 1 "00

5i.ro ta, 10 4<000

5#%o In! 1 <400

S.&it ** 1 1<000

a3&a 1 2<100

5i.ro ta, 10 4<000

: "

*#%ota$im# in! "

9#toroa* in! "

:anitidin in! "

'.&it 10** "

'.&it "** 4

n##d# 2 1

*#%ota$im# in! " 1+<200



9#toroa* in! " 1?<)00

:anitidin in! " 11<400

'.&it 10** " "<?00

'.&it "** " 2<400

r " 1)<000

n##d# 2 1 "00

In%&'#t dara( 1 +<100

In%&'#t dara( 1 +<100

i 1) 1 +<?00

r 2 12<000

%*1+ 1 1<00

&rin#,a- 1 4<=00

'.&it 10** 1 1<"00

a3&a 2 4<200

*#%o " 1+<200

'.&it ** " "<000

n##d# 2 1 "00

'.&it "** 4 "<200D 1 +<000

9#toroa* in! " 1?<)00

'.&it "** " 2<400

Amodi.in 10 m- + +<+00

: 1

In%&'#t dara( 1

i 20 1

D#$a In! 1 2<000

6&troit 1 4+<)00

6&ro'#mid# In! 4 )<)00

5#%tria$on# in! 1 <400*#%ota$im# in! " 1+<200

9#toroa* in! " 1?<)00


r 4 24<000

S.&it 10** 2 2<+00

a3&a 2 4<200

:L 2

6&troit 1

'.&it "** "

'.&it "** " 2<400

9#toroa* in! "

:anitidin in! 2

*#%ota$im# in! "

:L "

S.&it 10* "

A3&a 2

5i.ro ta, 10 4<000

Urin#,a- 1 4<400

5om,i#nt n#, ) =)<400



5i.ro ta, 10 4<000

I 20 2 1"<)00

In%&'#t dara( 1 +<100

i 5at( 1) 1 +<?00

6* 1+ 1 1<00

&rin#,a- 1 4<400

S.&it ** " "<000

N##d# 2" 1 "00

a3&a 1 2<100

*#%ota$im# in! " 1+<200

S.&it " ** +

In%&' Dara( 1

I7 1) 1

:L OGB =

S#an- O2 d' 1

D 1

9#toroa* in! "

S.&it 10 ** 1S.&it ** "

*#%ota$im# in! "

N#d# 2" 1

a3&a 1

6* 1+ 1

&rin#,a- 1

a3&a 2 4<200

6&troit 1 4+<)00

6&ro'#mid in! " +<+00

5#%tria$on# 2 10<)00

S.&it " ** 2 1<+00S.&it ** 2 2<000

S.&it 10 ** 2 2<+00

5#%tria$on# 2 10<)00

S.&it ** " "<000

S.&it " ** " 2<400

a3&a 1 2<100

7#ntoin " 2+<=00

5#%tri In! 2 10<)00

S.&it ** " "<000

S.&it " ** " 2<400

a3&a 1 2<100

7#ntoin " 2+<=00

D 1/4NS "

'.&it "** )

D 1/2NS 2

I7 22 1

In%&'#t Bia'a 1

'.&it "** 4<000

'.&it ** <000



:L 2 12<000

6&troit 2 ?"<+00


D 2 12<000

P@ 0<L 1 +<)00

D 1

'.&it ** "

'.&it "**

In%&' dara( 1

I7 1) 1

5#%tri 2 10<)00

'.&it "** 1 )00

'.&it ** 2 2<000

.(amino " 1<000

%*1+ 1

a3&a 1

Urin#,a- 1

D 1/4NS 2San'&in N 1 100<)00

Udo.a 2

" ay '#an- 1

6&ro'#mid in! "

5o.ram# 1

D#$a In! 1

" ay '#an- 1 +<200

D#$a In! 1

S.&it ** 2 2<000

d 1/4 2 1)<200

D 1na* 0< 1

S.&it ** 2

S.&it " ** 2

D#$a In! 1

'.&it "** 2 1<+00

:L 2 12<000

na* 0< 1 ?<100

S.&it 10** 2

D; 1

P@ 0<L 1

:anitidin in! 2

'.&it ** 1

'.&it "** 2

In%&' dara( 1

:L 10

I7 1) 1

D 1

:#ian 1 <00

I7 20 1 +<?00



6* 1+ 1 1<00

&rin#,a- 1 4<400

'.&it ** " "<000

'.&it "** 10 )<000

*#%ota$im# in! " 1+<200

9#toroa* in! " 1?<)00

I7 22 1 +<?00

In%&'#t Bia'a 1 4<=00

'.&it "** " 2<400

'.&it "** " 2<400

'.&it ** 4 4<000

I7 22 2 1"<)00

In%&'#t Bia'a 1 4<=00

D 1/4NS 2 1)<200

D40 " =<200

G#m%i,ro8i 1 +<000

S.&it " ** 4 "<200

:L OGB "0<000In%&'#t Bia'a 1 4<=00

I7 5at( 20 1 +<?00

&rin#,a- 1 4<400

a3&a " +<"00

5#%tri In! " 1+<200

S.&it 10 ** + =<)00

S.&it ** <000

S.&it " ** 4<000

N##d# 2 1 "00

6&ro'#mid in! 2 4<400

'.&it "** 2 1<+00In%&' Bia'a 1 4<=00

na* 0< " 20<400

I7 20 1 +<?00

Om#.ra8o# In! 2 1=?<+00

5#%tria$on 2 10<)00

S.&it 10 ** " "<?00

S.&it ** " "<000

S.&it " ** " 2<400

N#d# 2 1 "00

5a.tro.i 2 1" 2<+00

na* 0< 1 ?<100

N#d# 2 1 "00

6&ro'#mid in! " +<+00 +<+00

S.&it 10** 2 2<+00 2<+00

'.ironoa*ton# 4 2<000

6&troit 1 4+<)00

5#%tri 2 10<)00

S.&it "** " 2<400

A3&a 1 2<100



D 1/4 2 1)<200

:#ian 2 11<000

na* 0< 1 ?<100

%&ro'#mid in! " +<+00

'.&it "** 2 1<+00

'.&it ** 2 2<000

6&ro'#mid I,! 2 4<400

D&*oa$ '&. 2 2<400

: 1

D 1

In%&'#t Bia'a 1

S&r%o 20 1

6&troit 2

:anitidin in! 2

S.&it "** +

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In%&'#t dara( 1 +<100

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i 1) 1 +<?00

6* 1+ 1 1<00

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r 4 24<000na* 1 +<)00

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D#$a In! " <=00

:anitidin in! 2

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S.&it 10* 1 1<"00

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9#toroa* in! " 1?<)00

D 1 +<000

P@ 0<L 1 +<)00

6&ro'#mid# In! 2 4<400

In%&' dara( 1

I 1) 1



:L 4

6* 1+ 1

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S.&it 10** 1

'.&it ** "

S.&it "** 4

n##d# 2" 1

A3&a 2

*#%ota$im# in! "

D 1

9#toroa* in! "

I7 1) 2

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:L 4

6* 1+ 1

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a3&a 1

S.&it "** 4S.&it ** "

S.&it 10** 1

*#%ota$im# in! "

N##d# 2" 1

9#toroa* in! "

a'am M#%#namat 20

S.&it " ** 2

In%&'#t dara( 1 +<100

i 1) 1 +<?00

:L " 1)<000

a3&a 1 2<100S.&it 10* 1 1<"00

'.&it "** 4<000

In%&'#t dara( 1

S.&it 10**< "

S.&it ** "

S.&it "** "

i 1) 1

r "

D 2

:anitidin in! 2

5#%tri 2

N##d# 2 1

A3&a 1

5i.ro ta, 10

5i.ro ta, 10

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&rin#,a- 1 4<400

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a3&a 1 2<100

In%&'#t Bia'a 1 4<=00

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S.&it ** " "<000

S.&it " ** 4 "<200

N##d# 2 1 "00

Lod#m ta, 10 14<000

5#%tria$on# in! 2 10<)00

S.&it 10** 1 1<"00

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5#%tria$on# in! 2

a3&a "

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D 1/2NS "

Na* 1 +<)00

6&ro'#mid# In! 1 2<200'.&it 10*** 1 1<"00

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S&r%o 20 1 +<?00

In%&'#t dara( 1 +<100

S.&it 10** " "<?00

S.&it ** " "<000

S.&it "** 4<000

N##d# 1 "00

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6&troit In% 2 ?"<+00

Na* 0< 1 +<)00%&ro'#mid in! 2 4<400

:anitidin# in! 2 "<400

5#%tria$on in! 2 10<)00

D40; 2 4<)00

In%&'#t Bia'a 1 4<=00

I 20 2 1"<)00

r 1 +<000

*#%tri 2 10<)00

ranitidin in! 2 "<400

'.&it "** 2 1<+00

'.&it ** 2 2<000

'.&it 10** 2 2<+00

n##d# 2 1 "00

a3&a 1 2<100

D 1 +<000

na* 2 1"<+00

5#%ota$im 1 4<)00

5i.ro In% 1 2+<400

A3&a 1 2<100



6ar'i$ 2 4<+00

G#m,i,ro$i "00 10 4<000

I7 5at( 1) 1 +<?00

In%&'#t dara( 1 +<100

S.&it " ** 2 1<+00

N##d# 2" 1 "00

:L OGB 2 12<000

D; 1 +<000

P@ 0<L 1 +<)00

:anitidin in! 2 "<400

*#%ota$im# in! 2 ?<+00

5i.ro In% 2 2<)00

a3&a In! 1 2<100

S.&it 10 ** 2 2<+00

S.&it " ** " 2<400

P@ 0<L 2 1"<+00

S.&it 10 ** 2 2<+00

S.&it " ** 2 1<+00a3&a In! 1 2<100

5#%tri In! 2 10<)00


S.&it ** " "<000

S.&it " ** 2 1<+00

P@ 0<L 1 +<)00

S.&it 10 ** 1 1<"00

S.&it " ** 2 1<+00

a3&a In! 1 2<100

P@ 0<L 1 +<)00

S.&it ** 1 1<000S.&it " ** 2 1<+00

S.&it " ** ) +<400

S.&it 10 ** 1 1<"00

D 1/2NS "

In%&'#t dara( 1 +<100

M&*&' 1 10<+00

In%&'#t Bia'a 1 4<=00

I7 20 1 +<?00

:L OGB " 1)<000

5#%tria$on# In! 2 10<)00

5i.ro In% 2 2<)00

9#toroa* in! " 1?<)00

'.&it ** 2 2<000

a3&a In! 2 4<200

D 1/2 NS "

5#%tria$on in! 2

S.&it 10 ** 2

S.&it " ** 2

m&*&' 1



D#$a In! 2 "<)00

S.&it " ** ) +<400

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n#d# 2" 1 "00

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9#toroa* in! " 1?<)00

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5#%tria$on# 2 10<)00

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*i.ro in% 1 2+<400

S.&it 10 ** 1 1<"00S.&it " ** " 2<400

a3&a in! 1 2<100

:L OGB 1 +<000

5#%tria$on# 1 <400

a3&a in! 1 2<100

S.&it 10 ** 2 2<+00

S.&it " ** 2 1<+00


*#%ota$im# in! 2 ?<+00

*i.ro in% 2 2<)00

%&ro'#mid in! 2 4<400%i$ot#d# 2 "=<400

a3&a in! 1 2<100

S.&it 10 ** 1 1<"00

S.&it " ** " 2<400

I7 5at( 20 2 1"<)00

P@ 0<L 2 1"<+00

In%&'#t Bia'a 1 4<=00

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5#%tri In! 1 <400

Om#.ra8o# In! 1 )?<)00

a3&a In! 1 2<100

S.&it ** " "<000

S.&it 10 ** " "<?00

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In%&'#t dara( 1 +<100

P@ 0<L 1

P@ 0<L 1

:anitidin# in! 2

'.&it "** 1



'.&it 10** 1

7i**iin In! 2 ?<000

-#ntami*in in! 1 "<)00

'.&it "** 10 )<000

P&- In! 1 2<00

S&r%o 24 2 1"<)00

a3&a In! 1 2<100

D40; 2 4<)00

In%&'#t dara( 1 +<100

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S.&it 10** 1 1<"00

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9#toroa* in! 4 2+<400

5i.ro in%&' 2 2<)00

: " 1)<000

S.&it 10** 2 2<+00

S.&it "** 4 "<200

5#%tri 1 <400

r 2 12<000

Na* 0< 2 1"<+00

5#%tri 1 <400:anitidin in! 2 "<400

D 1 +<000

Na* 0< 1 +<)00

S.&it 10** 1 1<"00

S.&it "** 4 "<200

Na* 0< 1 +<)00


*#%o 2 ?<+00

*i.ro%$a*in in%&' 2 2<)00

S.&it 10** " "<?00

S.&it ** 2 2<000

S.&it "** 2 2<+00

5om,i#nt n#, 1 ?<)00

:L " 1)<000

a3&a In! 2 4<200

5#%tria$on# In! 2 10<)00

A3&a In! 2 4<200

-#ntami*in in! " 11<400

D; 2 12<000



:L OGB 2 12<000

S.&it 10** 2 2<+00

S.&it "** " 2<400

:L OGB 2

P@ 0<L 1

In%&'#t Bia'a 1

I 20 1

5#%tria$on# In! 2

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S.&it 10** 4

S.&it ** 4

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S.&it ** 2 2<000

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: 1 +<000

: 2 12<000

*#%tri 2

D#$a In! "

5om,i#nt n#, "

*#%tri 2 10<)005i.ro in%&' 2 2<)00

Lo#no$ 0<+ 2 "1+<)00

S.&it 10** 2 2<+00

S.&it ** 2 2<000

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S.&it 10** 2 2<+00

S.&it ** 2 2<000

S.&it "** 2 1<+00

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r " 1)<000

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I 20 1 +<?00

Noa-in in! 2 14<)00

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S.&it ** 2 2<000

S.&it "** 4 "<200

5a.to.ri 2 1<000

No#rty 10 <000

In%&' dara( 1 +<100



I7 20 2 1"<)00

:L " 1)<000

'.&it "** " 2<400

D 1/4 " 2=<"00

'.&it "** 1 )00

I 1) 1 +<?00

In%&'#t dara( 1 +<100

'.&it "** 1 )00

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5#%tria$on# In! 2 10<)00

S.&it 10** 2 2<+00

S.&it "** 2 1<+00

:L 2 12<000

D 1 +<000

S.&it "** 4 "<200

5#%tria$on# In! 2 10<)00

9#toroa* in! 4 2+<4005i.ro in% 2 2<)00

S.&it 10** 2 2<+00

S.&it "** 4 "<200

a3&a In! 1 2<100

5#%tria$on# In! 2 10<)00

S.&it 10** " "<?00

S.&it "** 2 1<+00

*#%ota$im# in! 2 ?<+00

%&ro'#mid in! " +<+00

5i.ro in% 2 2<)00

'.&it 10**** 2 2<+00S.&it "** 4 "<200

5#%tria$on# In! 2

S.&it 10** 2

''.&it "** "

S.&it ** 2

5#%tria$on# in! 2 10<)00

S.&it 10** 2 2<+00

S.&it "** 2 1<+00

In%&'#t dara( 1 +<100

I7 1) 1 +<?00

d 1 +<000

%* 1+ 1 1<00

&rin#,a- 1 4<400

S.&it 10** 1 1<"00

S.&it ** " "<000

S.&it "** " 2<400

D#$a In! 2 "<)00

a3&a In! 1 2<100

N##d# 2" 1 "00



*#%ota$im# in! " 14<400

"42<"00 1<1+<400 "<=40<)00 "<0+<?00 "2+<100



BPJS AS9ES BPJS :SB

4<400

2<100

1<+00

2<000

"<200

"<000

4<=00

BPJSJAM9ESMAS

BPJSMANDI:I

BPJSJAMSOSTE9



<400

"00

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2=<"00

2<400

"<000

10<)00

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1)<20010<)00

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+00

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10<)00

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2<000

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)?<)00

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+<?00

1<00

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1<"00

+<400

"<000

1+<200

4<000

+<000



1)<20010<)00

1<+00

"<)00

4<=00

1)<000

+<?00

2<400



4<000

4<000



+<000

+<?00

+<100

1)<000

1+<200

1?<)00

11<400

"<?00

"<200

"00



+<000

+<100

+<?00

12<000

4+<)00

2<400

1?<)00

=<+00

1+<200

1)<000

"<?00

4<200



4<)00

+<100

+<?00

42<000

+<100

+<000

1?<)00

1<"00"<000

1+<200

"00

2<100

1<00

4<400

2=<"00

2<400

1)<200

+<?00

4<=00



+<000

"<000

4<000

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1<00

2<100

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2?<+00

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+<+00

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2<000

2<000

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2<000

1<+00

2<000

2<+00

+<000

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1<000

1<+00

+<100

+0<000

+<?00

+<000





+<000

+<000

4<=00

+<?00

?"<+00

=<+00

4<)00

"<000

1)<20012<000

24<000

+<?00



4<=00

1+<200

=<+00

"<?00

"00

"<000

2<400

"<400

2<+001<000

+<100

+<?00



24<000

1<00

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1<"00

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"00

4<200

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+<000

1?<)00

1"<)00

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24<000

1<00

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2<100

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1<"00

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"00

1?<)00

4<000

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10<)00

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10<)00

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2=<"00

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4<000

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2?<400



10<)00

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2<000



1<"0<400 1<01"<=00 44<000 +<200 1?4<000



TANGGAL NAMA PASIEN BPJS GOLONGAN NAMA OBAT

2/2/2014 Ny a(y&ni BPJS 9 T#n'o*r#. +F

2/2/2014 N> I'nani BPJS 9 M#t%ormin ta,

dia#r'a ta,

%&ro'#mid# ta,

NyP&!i BPJS 9 Amodi.in# M-

2/14/2014 An Ama BPJS 9 :#ian

An M :i8y 9A:EB P5t 'yr

2/1=/2014 An Pri'ta UMUM 5indami*in 10

2/1)/2014 Ny M&!i :a(ay& BPJS 9 dia#r'a ta,

M#t%ormin ta,

Tn Marno BPJS A Om#.ra8o *a.

Ny Siti Ma'titi UMUM Amodi.in# 10 m-

Ny 9a'mira( UMUM Amodi.in 10 m-

Sima'tatin 10 m-

Tn :amidi UMUM Amodi.in 10 m-2/1?/2014 Ny Sa!iy#m BPJS AS9ES Amodi.in m-

%&ro'#mid# ta,

Ny Endan- BPJS A Om#.ra8o *a.

Tn Hartono BPJS A Amodi.in m-

So(o,ion

2/20/2014 An Ama UMUM Dom.#ridon 'yr

2/24/2014 An<6ar(an BPJS 9 a'a 10$4

2/2/2014 Tn Sa,ran- BPJS A So(o,ion

Amodi.in# M-

Ny S&tarni BPJS AS9ES 5a.to.ri 2

2/2=/2014 Ny Sriyati UMUM Gim#.irid 1m-Tn S&tomo UMUM Amodi.in# 10M-

Tn Sidi P&rnomo BPJS A Amod.in# 10M-

2/2)/2014 NySi'ati UMUM Gim#.irid 1m-

TOTAL

PC UMUM ?)<000

PC BPJS 9ELUA:GA 1+<400

PC BPJS ANGGOTA ""<+00

PC BPJS AS9ES 1<00

PC 9A:EB 2<400"14<?00



JUMLAH

HA:GA PASIEN

UMUM BPJS ANGGOTA BPJS AS9ES

1 =0<=00

1 "<000

10 =<000

) 1<+00

10 <000

1 <00

1

+ "<000

+0 42<000

"0 +<000

10 <000

22 1=<+00

14 11<200

14 4<200

14 11<2001 =<00

10 2<000

10 <000

20 10<000

) 2<400

1 10<)00

2 +<+00

10 "<000

"0 1<000

+0 +<000

20 12<00014 11<200

14 11<200

2) 1+<)00

?)<000 1+<400 ""<+00 1<00

BPJS9ELUA:GA

BPJSJAM9ESMAS



BPJS MANDI:I 9A:EB

2<400

2<400




3/1/2014 NyEi BPJS 9

An :#(andia BPJS U

N> Sa!iy#m BPJS BPJS

By Ny N&r 9om'a( UMUM


Ny Eo BPJS 9

Tn Bam,an- BPJS A

Tn Sadi BPJS A

Tn a'i' BPJS A

BON 79

"/2/2014Ny M#i# BPJS 9

Ny.Ri)a >mum

-n.Ra!ani)a ;

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N> :ia >(>(

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Tn amban" -

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3/11/2014Ny. irma TNI



Ny.ri lestari >(>(

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Tn. Raiman -

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-n.N$va9ira ;

Tn. aniin -;?

Ny. <eni ur9ati >(>(

"/2/2014 Tn. +ibyant$r$ -

Tn D(i,yantoro -

An 9(an8a ;

Ny 7atemi >mum

N7 <eni >(>(

Tn Panidin -;?

y.;an,a (aniri

Ny. iti umartini >(>(

Tn. aniin >(>(

Tn. +ibiyant$r$ -



3/2#/2014 Ny. @atini >(>(

Tn. Imam >(>(

Tn.aniin bp%s -

Ny ri >ntari -;?

Tn Di,iyantoro -

Tn Imam bp%s a

N> Siti S&martini >(>(

Ny Sri Untari -;?

By 9(an8a >(>(

3/2=/2014 Ny. itria >mum

Ny. ?)$ >mum

Ny.iti sumarsini >(>(

Ny.ri >ntari -;?

Ny.(eria >(>(



N7 @atini bp%s %a(;?(-

N7 ri >ntari -;?

Tn +ibyant$r$ bp%s -

Tn Imam -

Ny +anria (-N+IRI

"/2)/2014 NN. -mana ;

Ny.ri @ulanari (aniri

Ny.Insap @ati ams$tec



3/2B/2014 Ny. >mi R$i)!aniati -;?

Ny. ri >ntari -;?

y. Ny. >mi >

y. Ny. >mi - >

ny S&a'tri >mum

Tn ;abul >(>(

Ny Sri Untari -;?

Tn Imam -

N7 @atini -(;?(-

"/"0/2014 Tn. ;abul -(;?(-

y. ;an,a -'ila >

Ny. N$vita ;

Ny. iti Nur aia ;



Ny. +eiby ;

Ny. iti nur aia ;

y. Ny. N$vita ;

Ny. @inarti) >mum

Tn. Imam >

Ny. ri >ntari >

Ny. @atini -(;?(-

Ny. iti Nur >

"/"1/2014 Sdr M M&min >

Nn S#rita bp%s )

NySri :a(ay& BPJS 9



NnAmanda BPJS

Tn9a,& BPJS UMUM

NySri Untari BPJS AS9ES

TnImam BPJS A



NAMA OBAT JUMLAH

UMUM BPJS UMUM

S#an- O2 d' 1 +00

*#%ota$im# in! 1 4)00

'.&it 10*** 1 1"00n##d# 2 1 "00

I 20 1

In%&'#t Bia'a 1

S.&it ** "

'.&it "** "

D40; 1 2400

5#%tria$on# In! 1

5i.ro In% 1 2+400

%&ro'#mid in! 1 2200

5a.to.ri 2 10

'.&it "** 2

'.&it "** 2

a3&a In! 1

9#toroa* in! 2

a3&a In! 1

S.&it 10** 2

Hand'*oon Non 100 1"0000

%&t(roit 4

iv 20 2Infuset iasa 1

spuit 3cc 5

*eftria&$ne In% 2

a'ua In% 2

spuit 10cc 2

neele 23 1

neele 25 1

Lev$C$&acin 1 =8000

$rbivent 5 43500

li&$tite 3 5#1005 1/2 2 18200

puit 3 cc 2 1#00

cef$ta&ime in% 1 4800

puit 3 cc 5 4000

elan" 2 9s 1 #500

puit 5 cc 3 3000

puit 10 cc 3 3B00

BPJS9ELUA:GA



*eftria&$ne In% 2 10800

Nele 25 1 300

a'ua In% 2 4200

Lev$C$&acin 1 =8000

+ 5 1 #000

+ 5 1 #000

+ 5 1 #000fur$semi in% 3 ##00

spuit 3cc 4 3200

spuit 3cc 4

*eftria&$ne In% 1

puit 10cc 3

a'ua In% 1

spuit 3cc 2

*eftria&$ne In% 2

puit 10c 2

spuit 3cc 4

a'ua In% 1


utr$lit 3 140400

puit 10c 2 2#00

spuit 3cc 3 2400

a'ua In% 1 2100

*eftria&$ne In% 1

spuit 3cc 4

5 1/4 2 18200spuit 3cc 1 800

-m$& Tab 10 4000

puit 10 cc 1 1300

(ucus e& 1 10#00

puit 3 cc 1 800

a'ua In% 1 2100

I 22 1

Infuset iasa 1 4=00

spuit 3cc 3 2400

Infuset iasa 1 4=00spuit 3cc 3 2400

spuit 3cc 2

metr$ tab 15

puit 10cc 2

puit 3cc 2

a'ua In% 1

puit 5cc 2



Lev$C$&acin 1 =8000

;- ?N 3 3 3#B00

I *at! 22 1 #B00

I *at! 24 1 #B00

puit 5 cc 1 1000

Infuset iasa 1 4=00

+5 1/4 3 2=300Ranitiine tab 10 2000

*ipr$ tab 10 4000

+10 1 ##00


puit 10 cc 1 1300

puit 3 cc 3 2400

a'ua In% 1 2100

puit 3 cc 3 2400

puit 3 cc 3

Lev$C$&acin 1 =8000

Infus +ara! 1 #100

I 18 2 13800

puit 3 cc 3 2400

puit 10 cc 1 1300

a'ua In% 1 2100

Infuset iasa 1

Iv *at! 20 1

puit 10 cc 2

puit 5 cc 2puit 3 cc 2

Neele 25 1

*eftria&$ne In% 2

mepra,$le in% 2

Neele 25 1

spuit 10cc 4

Ranitiine tab 10 2000

+5 1 #000

+e&a in% 4

puit 3 cc 3*eftria&$ne In% 2

mepra,$le in% 2

puit 3 cc 2 1#00

*erftria&$ne 2 10800

puit 10 cc 1 1300

Nele 25 1 300

+5 1 #000



Lev$C$&acin 1 =8000

+5 1 #000

+5 2 12000

+e&a in% 3 #000

puit 3 3 2400

Infuset iasa 1

iv 20 2RL 3

puit 10ccc 3

puit 5cc 3

Neele 25 1

+ 5 2

cef$ta&ime in% 2

c 1# 1 15500

>rine ba" 1 4400

-'ua in% 1 2100

lu" 1 8200

ur$semi in% 10 22000

Neele 23 1 300

spuit 3cc 1 800

Infuset ara! 1 #100

*ipr$ Tab 10 4000

I *at! 20 1 #B00

(etf$rmin Tab 15

nancentr$n in% 2 8#00

nancentr$n in% 2 8#00Lev$C$&acin 1 =8000

cef$ta&ime in% 2

a'ua In% 1

puit 5cc 2

puit 3cc 1

*eftria&$ne In% 2

puit 10cc 4

puit 3cc 2

+ 40 1 2400

iv 18 1 #B00c 1# 1 15500

>rine ba" 1 4400

spuit 10cc 1 1300

a'ua In% 1 2100

RL 4

Infus +ara! 1

I 20 1



*eftria&$ne In% 2

entamisin in% 1

puit 10cc 3

puit 3cc 3

Neele 25 1

3@ay elan" 1

a'ua In% 1lu" 1 8200

I 20 1 #B00

iv 20 1

Infuset iasa 1

*l$pramel 4

e&anta syr 1

,yf$rt 3

+5 2

+40: 2 4800

entamisin in% 3

e&a in% 2

puit 10cc 2

puit 5cc 1

puit 3cc 2

cef$ta&ime in% 2

puit 10cc 1

puit 5cc 1

puit 3cc 1

ur$semi in% #puit 5cc 2

puit 3cc 1

Lev$C$&acin 1 =8000

Infuset ara! 1 #100

iv 18 2 13800

spuit 3cc 5 4000

+e&a in% 2 4000

entamisin in% 1 3800

c 1# 1 15500

>rine ba" 1 4400-'ua in% 2 4200

puit 10cc 1 1300

puit 5cc 3 3000

ur$semi in% #

spuit 3cc 3

*eftria&$ne In% 2

entamisin in% 2



puit 10cc 3

puit 5cc 2

-'ua in% 2

Lev$C$&acin 1 =8000

+e&a in% 4

spuit 3cc 3

Lev$C$&acin 1 =8000+e&a in% 3

spuit 3cc 4

ur$semi in% #

spuit 3cc 3

Iv 24 1 #B00

I 20 1 #B00

Try elan" 1

Infus isa 1

*eftria&$ne In% 1

puit 10 cc 2

-'ua in% 1

+40: 1 2400

)cl 1 2500

entamisin in% 1 3800

puit 3 cc 5 4000

infus iasa 1 4=00

Iv 20 1 #B00

puit 10 cc 3 3B00

puit 5 cc 3 3000puit 3 cc 3 2400

Nele 25 1 300

Nacl 1 #800

ur$semi in% 20 44000

e&a in% 3

ranitiine in% 2

Nacl 2

spuit 3cc 4

spuit 3cc 3 2400

iv 18 2fc 1# 1

>rine ba" 1

spuit 10cc 1

spuit 5cc 3

neele 23 1

spuit 3cc 5

cef$ta&ime in% 3



+5 1

Infus iasa 1 4=00

iv 20 1 #B00

-ml$ipine 5 10 5000

puit 3 cc 5 4000

puit 5 cc 2 2000

-ml$ipine 5 10 11000a'ua In% 2 4200

puit 5cc 3 3000

puit 3cc 4 3200

Infuset iasa 1

I *at! 20 2

*eftria&$ne In% 2

puit 5 cc 2

puit 3 cc 1

Neele 25 1

a'ua In% 1

>rine ba" 1

RL 3 18000

+5: 1 #000

065 L 1 #800


Trama$l In% 3 23100

nancentr$n in% 3 12B00

puit 3 cc 3 2400

puit 3 cc 2 1#00*eftria&$ne In% 2

puit 3 cc 2

puit 10 cc 1

(ucus e& 1 10#00

puit 10cc 2 2#00

-'ua in% 1 2100

c 1# 1 15500

>rine ba" 1 4400

Infuset ara! 1 #100

Iv 18 1 #B00puit 3cc 4 3200

+e&a in% 2 #000

Infuset iasa 1 4=00

Iv 20 1 #B00

nancentr$n in% 3 12B00

puit 5cc 3 3000

spuit 3cc 3 2400





neele 25 1

*eftria&$ne In% 2

*apt$pril 25 3

*apt$pril 25 # 1200

puit 5 cc 2 2000

puit 3 cc 1 800

Infus +ara! 1puit 3 cc 8

puit 5 cc 3

puit 10 cc 1

I 18 1

c 1# 1

>rine ba" 1

a'ua In% 1

Nele 23 1

cef$ta&ime in% 3

elan" 2 9s 1

+5 1

ur$semi in% 1

*eftria&$ne In% 2

puit 3 cc 4

Neele 25 1

a'ua In% 1

Infuset ara! 1 #100

I *at! 20 2 13800

*eftria&$ne In% 2 10800puit 10 cc 2 2#00

Neele 25 1 300

-'ua in% 1 2100

puit 3 cc 1 800

relivan 3 1#500

puit 3cc 1 800

cef$ta&ime in% 2 B#00

-'ua in% 1 2100

Neele 25 1 300

iv 22 1 #B00iv 24 1 #B00

*eftria&$ne In% 2

puit 3cc 3

-'ua in% 1

I 24 4 2=#00

;-- 10D4 1 4#00

I 20 1 #B00



Infuset iasa 1 4=00

c 1# 1 15500

>rine ba" 1 4400

spuit 10cc 2 2#00

puit 5cc 2 2000

-'ua in% 2 4200

Infuset ara! 1 #100iv 18 1 #B00

fc1# 1 15500

>rine ba" 1 4400

puit 3cc 8 #400

puit 5cc 3 3000

puit 10cc 1 1300

Neele 23 1 300


elan" 2 9s 1 #500

)et$r$lac in% 1 ##00

Infuset ara! 1 #100

iv 18 1 #B00

fc 1# 1 15500

>rine ba" 1 4400

spuit 3cc 8 #400

spuit 5cc 3 3000

spuit 10cc 1 1300

neele 23 1 300

cef$ta&ime in% 3 14400elan" 2 9s 1 #500

+5 1 #000

)et$r$lac in% 3 1B800

a'ua In% 2 4200

(ucus e& 1 10#00

(ucus e& 1 10#00

Inu&in 1 2=00

>$pa 2 2B#00

spuit 5cc 1 1300

!amin$v 1 5000nancentr$n in% 2 8#00


puit 10 cc 3 3B00

puit 5 cc 3 3000

puit 3 cc 3 2400

Neele 25 1 300

a'ua In% 1



ur$semi in% 1

puit 5 cc 1

puit 3 cc 1

*$ein 10 m" Tab 10

IN> I-- 1

puit 3 cc 1

nancentr$n in% 2puit 5 cc 1

puit 10 cc 1

puit 10 cc 1 1300

Nele 25 1 300

nancentr$n in% 2 8#00

puit 3 cc 3 2400

a'ua In% 1 2100

Iv 20 1

Infus I- 1

puit 10 cc 4

puit 5 cc 3

puit 3 cc 4

a'ua In% 2

utr$lit 1

*erftria&$ne 2

ur$semi in% 3

)et$r$lac in% 3

puit 10 cc 2


a'ua In% 1

imvastatin 10

(ucus e& 1 10#00

Infuset ara! 1

Iv 18 1

c 1# 1

>rine ba" 1

puit 5cc 2

puit 3cc 4Neele 23 1

cef$ta&ime in% 3

Neele 23 1 300

ur$semi in% 2 4400

)et$r$lac in% 3 1B800

*l$pramel 3 8400

*efar$&il *aps 10 8000



+5 1/2N 1 B100

Iv 20 1

Infus iasa 1

elan" 2 9s 1

puit 10 cc 5

puit 5 cc 5

puit 3 cc 3Nele 35 1

+ea& in% 3

-sam Trane&anat in% 3

*eftria&$ne In% 2

-'ua in% 2

Iv 20 1 #B00

Infus I- 1 4=00

puit 5 cc 2 2000

puit 3 cc 5 4000

puit 5cc 3

-'ua in% 1

Infuset ara! 1 #100

I 18 1 #B00

ur$semi in% 1

puit 3cc 1

+5 1/2N 4

*eftria&$ne In% 2

puit 5cc 2

5 1spuit 3cc 1 800

spuit 10cc 1 1300

iv 24 1 #B00

alsartan 80m" 10 48000

Neele 23 1 300

+ 5 1 #000

+e&a in% 3

cef$ta&ime in% 2

ur$semi in% 1


a'ua In% 1 2100

-sam Trane&anat in% 1 5100

puit 5cc 1 1000

!amin$v 3 15000

Neele 25 1

puit 10cc 1



a'ua In% 1 2100

puit 10cc 3 3B00

puit 5cc 4 4000

puit 3cc 3 2400

ut!r$lit 1 4#800


a'ua In% 1 2100puit 10 cc 3 3B00

puit 3 cc 3 2400

puit 5 cc 3 3000

Neele 25 1 300

puit 3 cc 3

puit 10 cc 1

Infus isa 1

cef$ta&ime in% 3

puit 10cc 3

puit 3cc 2

puit 5cc 2

*eftria&$ne In% 2

puit 10cc 3


puit 3cc 2 1#00

spuit 10cc 2 2#00

a'ua In% 1 2100

Infuset iasa 1

I 20 1cef$ta&ime in% 3

a'ua In% 1

puit 3cc 3

puit 5cc 3

spuit 10cc 3

Neele 25 1

Iv 24 # 41400

r$feni # 30#00

;ut$in in% 10 288000

+e&aE in% 2 4000limepiri 1m" 1# B#00

mepra,$l 8 4000

*eftria&$ne In% 2

Infus +ara! 1 #100

urC$ 18 1 #B00

+5 1 #000

c 1# 1 15500



>rine ba" 1 4400

puit 10 cc 1 1300

-'ua in% 1 2100


puit 5 cc 3 3000

puit 3 cc 5 4000

puit 3cc 3spuit 10c 2

*eftria&$ne In% 1

>IT 10* 2

puit 3cc 2

puit 10c 1

*eftria&$ne In% 2

>IT 10* 3

Infuset ara! 1

iv 18 1

+5 1

c 1# 1

>rine ba" 1

>IT 10** 1

puit 5cc 3

cef$ta&ime in% 3

puit 3cc 4

-'ua in% 2

Infuset ara! 1 #100

Rl 2 12000*eftri 2 10800

spuit 3cc 3 2400

spuit 5cc 3 3000

neele 25 1 300

-'ua in% 1 2100

Infus +ara! 1

Iv 18 1

c 1# 1

>rine ba" 1


puit 3 cc 5

cef$ta&ime in% 3

Nele 23 1

a'ua In% 1

elan" 2 9s 1

Infus +ara! 1



c 1# 1

>rine ba" 1

puit 5 cc 3

puit 10 cc 1

cef$ta&ime in% 3

a'ua In% 1

Iv 18 1+5 1

puit 3 cc 4

Infuset ara! 1

iv 18 1

>rine ba" 1

spuit 10cc 4

spuit 3cc 4

neele 23 1

a'ua In% 1

5: 1

Trama$l In% 2

imvastatin 10

(ucus e& 1 10#00

(ucus e& 1 10#00

!amin$v 4 20000

puit 10cc 2 2#00

puit 5cc 2 2000

puit 3cc 2 1#00

puit 10cc 1puit 3cc 3

*eftria&$ne In% 1

a'ua In% 1

puit 10cc 2

puit 3cc 1

puit 3cc 4

imvastatin 10

Neele 25 8 2400

puit 3cc 8 #400

+e&a in% 2 4000puit 3cc 3 2400

Neele 23 1 300

Infuset ara! 1 #100

a'ua In% 1 2100

Infuset iasa 1 4=00

*eftri 1 5400

puit 10cc 3 3B00



puit 5cc 3 3000

puit 3cc 5 4000

Neele 25 1 300

Infuset iasa 1 4=00

relivan 2 11000

puit 3cc 3 2400

+5 2 12000;r 10 23000

imvastatin 10 3000

(ucus e& 1 10#00

+10 1 13500

!amin$v 1 5000

puit 10cc 1 1300

3 9ay selan" 1 32#00

$spar"in in% 1 1800

puit 10 cc 1 1300

*eftri In% 2 10800

puit 10 cc 1 1300

puit 5 cc 2 2000

puit 3 cc 1 800

+e&a in% 3

puit 5 cc 2

puit 3 cc 2

puit 3 cc 2 1#00

Infuset ara! 1 #100

iv 20 1 #B00*eftria&$ne In% 2 10800

-'ua in% 1 2100

spuit 10cc 3 3B00

puit 5cc 3 3000

puit 3cc 3 2400

neele 25 1 300

Infuset iasa 1 4=00

iv 20 1 #B00


-'ua in% 1 2100nancentr$n in% 2 8#00

spuit 10cc 3 3B00

spuit 5cc 3 3000

spuit 3cc 4 3200

neele 25 1 300

S.&it 10 ** " "?00

S.&it ** 1 1000



Na* 1L 2 1=200

6* 1+ 1 100

&rin,a- 1 4400

S.&it 10 ** 2 2+00

a3&a in! " +"00

amodi.in# 10 10 11000

Pro%#nid '&. 1 100

5#%tria$on# 2 10)00

9#toroa* " 1?)00

6&trit 2 ?=200

S.&it 10 ** 4 200

S.&it ** 2 2000

a3&a in! 1 2100

S#an- 02 D' 1 +00

S.&it " ** 2 1+00

S.&it ** 2 2000

a3&a in! 1

a3&a in! 1

3604=6300 160=36400 1623#6#00



HA:GA PASIEN

BPJS AS9ES BPJS MANDI:I

+?00

4=00

"000

2400

400

2000

1+00

1+00

2100

1"400

2100

2+00

1)=200

138004=00

4000

10800

4200

2#00

300

300

BPJS ANGGOTA

BPJSBPJS

BPJSJAM9ESMAS

BPJSJAMSOSTE9



3200

5400

3B00

2100

1#00

10800

2#00

3200

2100

5400

3200

#B00

1#00

3000

2#00

1#00

2100

2000



2400

4=00

#B00

2#00

20001#00

300

10800

1=B#00

300

5200

8000

240010800

1=B#00



4=00

1380018000

3B00

3000

300

12000

B#00

3000

B#00

2100

2000

800

10800

5200

1#00

24000

#100

#B00



10800

3800

3B00

1800

300

32#00

2100

#B00

4=00

11200

#000

12#00

12000

11400

4000

2#00

1000

1#00

B#00

1300

1000

800

132002000

800

13200

2400

10800

=#00



3B00

2000

4200

8000

2400

#000

3200

13200

2400

32#00

4=00

5400

2#00

2100

#000

=#00

13#00

3200



4=00

13800

10800

2000

800

300

2100

10800

#00

1300



4=00

B3#00

#B00

#500

##00

2400

2000#800

4400

1#00

1300

44001#00

4=00

#B00

#000

3B00

3000

2400



300

10800

#00

#100#400

3000

1300

#B00

15500

4400

2100

300

14400

#500

#000

2200

10800

3200

300

2100

10800

2400

2100



2100





#B00

4=00

#500

#500

5000

2400300

#000

15300

10800

4200

3000

2100

2200

800

32400

10800

2000

#000

#000

B#00

2200

20008000

300

1300



2400

1300

4=00

14400

3B00

1#00

2000

10800

3B00

4=00

#B0014400

2100

2400

3000

3B00

300

10800



24002#00

5400

2#00

1#00

1300

10800

3B00

#100

#B00

#000

15500

4400

1300

3000

14400

3200

4200

#100

#B00

15500

4400

13003000

4000

14400

300

2100

#500

#100



15500

4400

3000

1300

14400

2100

#B00#000

3200

#100

#B00

4400

5200

3200

300

2100

#000

##00

3000

13002400

5400

2100

2#00

800

3200

3000



#000

2000

1#00



2100

2100

=886=00 206200 #856B00 4#56200 2246200 1156=00

=6=246300

#326500

8635#6800



TNI











1380015500

4400

1300

3000

300

4000

14400



#000

4400





















#=6100 =6=246300




"/1/2014 TnSidi BPJS A G#m%i,ro8i "00

Ny Ta'o#mi UMUM d#$a*a. 12<

No#rty

"/"/2014 Tn Eo BPJS A 5i.ro Ta,

Nn Li'na BPJS U 5i.ro Ta,

AnI3,a UMUM Ondan*#tron ta,

"/4/2014 Ny Sri P&rnama BPJS 9 Om#.ra8o#

5i.ro Ta,

Tramado 5a.'

Tn Sidi BPJS A Amodi.in 10 m- ta,

3/5/2014 dr-Ad# BPJS A 5#%adro$i 00 m-

3/#/2014 Tn Sarmani UMUM Ondan*#tron In!

3/B/2014 Ny Ha%i8( UMUM Erytromi*in 20m-

Tn. armani >(>( ?rytr$micin 250 m"Ny Si'ati 9A:EB Gim#.irid# 1 m-

3/11/2014 Tn ar'ito UMUM Erytromi*in 20

"/1"/2014 Tn Sidi BPJS A Amodi.in 10 m- ta,

5am#o*

"/14/2014 M, Dia( BPJS A T#n'o*r#.# + In*(i

Ny Ety BPJS AS9#' Lomat&#

"/1)/2014 Ny M&!i BPJS U M#t%ormin

Ny S&tarni BPJS U 5a.to.ri 2 m-

Amodi.in 10 m- ta,

Ny Sri a(y&ni BPJS A Amodi.in 10 m- ta,

Ny S&darni UMUM Amodi.in 10 m- ta,

Tn Adi UMUM 5am#o*

"/20/2014 Ny Ani' UMUM Do$i$*in 100 m-

Ny Sri BPJS 9 Om#.ra8o#

"/21/2014 P9U 9aitid& ida(#'

3/23/2014 Ny D#i BPJS 9 5#%adro$i 00 m-

"/2/2014 Ny<S&darti &mUM Amodi.in 10 m- ta,

Ny S&yatmi BPJS 9 Amodi.in 10 m- ta,

Tn Bam,an- BPJS A 5od#in 10 m- Ta,

3/2=/2014 Ny Sri BPJS 9 Amodi.in m-

IGD Pro%#nid '&.



JUMLAH

HA:GA PASIEN

UMUM BPJS BPJS

10

1

10

10 4000

" ""000

+ "000

10 4000

) 2400

20 22000

10 )000

" ""000

40 20000

20 10000

20

20 10000

14 1400

14 )400

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S,'it 3 %%

Ny. Ain'n B,( MM in-'et ara



S'r-l" 18

S,'it %%

S,'it 10 %%

neele 23

*e-"tai)e in(

rina!

Antrain In(

An. 7e#ania BPJS DINAS In-'et Biaai# *at 24

Onan%etr"n

S,'it %%

S,'it 3 %%

Ny. Al-ini MM Antrain In(

Ny Tati+ BPJS MM I# 18

I# 20

in-'et ara

S,'it 3%%

An. 7e#aia BPJS DINAS $aen 3A

$aen 3B

S,'it 3%%Tn. TASri, BPJS DINAS 5'r"e)ie In(

Antrain In(

S,'it 3%%

S,'it %%


S,'it %%

S,'it 3%%

By. Ny.Ain'n BPJS MM S,'it 10%%

By= :ati+ MM M'%'

M'%'

Ny.:'ni BPJS MM In-' Dara

I# 18rina!

S,'it

S,'it 3

Tra)a"l

Nele 23

A&'a in(

Ny.Ani+ BPJS MM In-' Dara

I# 18

rina!

S,'it

S,'it 3

Tra)a"l Nele 23

A&'a in(

Tn.M'in BPJS MM elan! O2 w

In-' Biaa

I# 20

S,'it 10

S,'it

Sr Ai BPJS MM Antrain In(

S,'it %%



A&'a in(

4/2/2014 By=Ny. 7atna MM M'%'

By. Ny. 6atini M) M'%'

An. Bryan MM M'%'

Sr. Setyawan 6ii"n" BPJS DINAS elan! O2 w

rina!

A&'a in(

S,'it 10%%S,'it %%

S,'it 3%%

Neele 2

Ny. Sya-ri+a BPJS MM S,'it 3%%

Neele 23

Sr. T!ri etyawan BPJS DINAS Neele 2

ny Dwi BPJS MM *e-tria"ne

neele 2

S,'it 10%%

S,'it %%

S,'it 3%%

A&'a in( Ny L'tini B,( MM in-'et ara

i# 18

rina!

S,'it 10%%

*e-"tai)e in(

S,'it %%

S,'it 3%%

Tra)a"l

Ny Dwi 7ay' BPJS MM S,'it 3%%

S,'it 10%%

3 way elan!

!enta in(ea in(

SDr ADI BPJS MM *e-tria"ne

Antrain In(

S,'it 10%%

S,'it 3%%

4/2>/2014 Sr. Ani+ MM Antrain In(

Tn. A)ri9al BPJS DINAS in-'et ara

i# *at 20

A&'a in(

elan! O2 w

,'it 10 %%

S,'it %%S,'it 3 %%

Neele 2

By. Ny. Li%+a BPJS MM M'%'

Ny. Li%+a BPJS MM S,'it 3%%

in-'et ara

S'r-l" 18

S,'it 10%%

Neele 23

Ny. Dwi BPJS MM Onan%etr"n



!enta in(

r.ai BPJS MM Antrain In(

,'it 3

A&'a in(

Tn.Atawa BPJS INAS In-' Bia

I# 20

*e-tr

S,'it 10S,'it

S,'it 3

nele 2

A&'a in(

elan! O2 w

4/28/2014 Ny. <era BPJS MM in-'et ara

S'r-l" 18

S,'it 3 %%

S,'it 10 %%

A&'a in(

Sr. Setiawan BPJS INAS Onan%etr"n

*e-"tai)e in(Tn. I Nen!a BPJS INAS Pa)in"#

Ny. 7i+a BPJS MM in-'et ara

i# *at 18

A&'a in(

S,'it 3 %%

S,'it 10 %%

Ny. Li%+a BPJS MM S,'it 3%%

Ny. ;arti BPJS MM !enta in(

S,'it 3%%

elan! O2 w

S,'it 10%%

y. Ny. 7i+a BPJS MM M'%'By. Ny. ;arti BPJS MM M'%'

Ny.:'nita BPJS MM In-' Dara

i# 18

S,'it 3

S,'it 10

nele 23

,",ar!in in(

Sr.Tri BPJS INAS Onan%etr"n

SPIT 10

S,'it

S,'it 3

Sr.Ai BPJS MM Antrain In(,'it 10

,'it

,'it 3

Tn.AMI7L BPJS INAS S,'it 10

S,'it

Tn.Atawa BPJS DINAS <ent"lin

S,'it 10

S,'it

S,'it 3



Ny.Dwi BPJS MM !enta in(

ea in(

S,'it 10

S,'it

S,'it 3

4/2@/2013 Ny. P'(i At'ti+ BPJS MM in-'et ara

I< 18

S,'it 3%%S,'it 10%%

By. Ny. :'nita BPJS MM M'%'

By. Ny. P'(i At'ti+ BPJS MM M'%'

By. Ny. Al-ini BPJS MM S,'it 3%%

!enta in(

Ny. S',iyati BPJS MM In-'et Biaa

I# 20

S,'it 3%%

S,'it %%

Ny. :'li BPJS MM In-'et iaa

I< *at 20

S,'it %%S,'it 3 %%

S,'it 10 %%

Antrain In(

<ati!" Ta

Ny. S',iyati BPJS MM A)l"i,in )! Ta

Ny. Sri 6ay'tin BPJS MM in-'et ara

I< *at 18

rina!

S,'it 10 %%

S,'it 3 %%

S,'it %%

A&'a in(5'r"e)ie In(

Ny. Ia $'rniawati BPJS MM i# *at 18

in-'et ara

ea in(

rina!

S,'it 10 %%

S,'it %%

A&'a in(

S,'it 3 %%

Sr. Atawa BPJS INAS *e-tria"ne

S,'it 10%%

S,'it %%S,'it 3%%

A&'a in(

Ny. :'li Sety"wati BPJS MM Onan%etr"n

Antrain In(

S,'it %%

S,'it 3%%

Ny. S',iyati BPJS MM S,'it 3%%

tn. A)ir'l BPJS INAS aa) tranea)at in(

*e-tria"ne



S,'it 10%%

A&'a in(

Sr. Aitya BPJS MM Antrain In(

S,'it 10%%

S,'it %%

S,'it 3%%

Ny. Dwi BPJS MM *e-"tai)e in(

!enta in(S,'it 10%%

S,'it %%

S,'it 3%%

A&'a in(

Ny. S',arni MM Antrain In(

An. Ina BPJS INAS In-'et iaa

i# 20

A&'a in(

*e-tri

Antrain In(

S,'it %%

S,'it 3%%4/30/2014 ny 6i(i MM Antrain In(

Tn A)ir'l BPJS DINAS S,'it 10%%

Ny Dwi BPJS MM I# 20

Ny Ina BPJS MM *e-tria"ne

Antrain In(

N: 6i(i MM Antrain In(

Tn A)ir'l BPJS DINAS rina!

S,'it 10%%

A&'a in(

Ny Siti :'liati BPJS MM I# 20

in-'et ara

Ny 6ay' BPJS MM In-'et IASAI# 18

S,'it 3%%

A&'a in(

S,'it 10%%

elan! O2 w

B: N y Sri 6ay'tin BPJS MM M'%'

Tn A)ir'l BPJS DINAS S,'it 3%%

Neele 23

Tn. Atawa BPJS DINAS In-'et Biaa

Ny. Siti :'liati BPJS MM !enta in(

Antrain In(

S,'it 3%% Ny. Sri 6ay'tin BPJS MM 5'r"e)ie In(

S,'it 3%%

*e-"tai)e in(

$et"r"la% In(

I# 18

S,'it %%

elan! O2 w

A&'a in(

Nn. Ina BPJS INAS *e-tri



Antrain In(

S,'it 10%%

S,'it %%

S,'it 3%%

Ny. Dwi BPJS DINAS !enta in(

*e-"tai)e in(

S,'it 10%%

S,'it %%S,'it 3%%

Sr. Aitya BPJS DINAS Antrain In(

S,'it %%

S,'it 3%%

Tn. Atawa BPJS DINAS *e-tri

S,'it 10%%

S,'it %%

S,'it 3%%

Ny. S',riyatin BPJS MM S,'it 3%%

TOTAL

















JMLA;;A7GA PASIEN

MM BPJS MM BPJS DINAS

1 32=00

1 2=00

1 2=100

1 3=800

1 12=00

10 8=0002 2=00

2 4=800

1 1=00

1 =00

3 20=>00

=00

1 4=400

1 2=000

1 =100

3 3=000

3 2=400

2 12=2001 2=200

2 1=00

3 =000

2 1=00

2 2=000

1 =400

1 1=300

2 2=000

2 =400

1 1=000

1 2=100

2 10=8001 2=100

1 =100

1 32=00

1 800

1 =100

1 =@00

1 1=00

1 4=400

8 =400

3 3=000

1 1=300

2=0002 10=200

2 1=00

2 10=200

1 =100

1 =@00

1 1=00

1 4=400

1 1=300

3 3=000



4=800

1 4=300

3 14=400

2 2=800

1 =100

1 32=00

1 =00

3 1=0001 =000

3 24=000

2 1=00

1 8=000

1 2=200

2 1=00

2 10=000

2 4=000

2 1=00

2 10=800

3 24=000

2 1=002 2=000

2 2=00

2 1=00

1 4=>00

1 =@00

2 2=00

4 3=200

1 2=100

1 =00

10 @=000

1 4=>00

1 =@001 =@00

1 1=000

1 =400

4=000

2 2=00

2 4=400

1 2=200

3 2=400

2 1=00

2 2=800

4=000

3 3=@002 2=800

1 =400

1 10=00

2 11=000

2 1=00

2 @=00

3 3=000

2 13=800

1 =100



1 800

1 1=000

1 =100

1 =@00

1 1=00

1 4=400

2 2=00

3 14=400 12=000

2 1=00

1 2=200

3 2=400

1 8=000

3 24=000

2 10=800

3 3=@00

1 800

2 2=00

2 10=800

2 10=8002 2=00

4 4=000

1 800

3 24=000

2 2=00

3 3=000

3 2=400

3 2=400

2 2=00

3 2=400

1 =@00

1 4=>004 18>=200

3 3=@00

3 3=000

4=000

1 300

2 1=000

3 2=400

0 =000

3=000

1 =100

1 =@00

1 1=3002 1=00

8 8=000

3 14=400

3 1=300

1 4=800

1 =100

1 =@00

1 1=000

2 1=00



1 300

3 20=>00

2 @=00

2 2=00

1 2=200

2 2=00

3 2=400

2 1>2=0003 24=000

3 3=@00

3 2=400

3 24=000

1 8=000

2 2=000

4 3=200

1 4=>00

1 =@00

3 1=200

3 24=000

=00010 8=000

1 4=>00

1 =@00

3 3=000

1 =00

1 =00

1 =400

2 400

3 2=00

3 3=000

3 2=400

1 =@001 300

1 1=000

1 1=300

2 1=00

1 1=300

2 1=00

1 1=300

2 2=000

2 1=00

1 800

1 1=000

2 2=001 4=800

2 1=00

2 2=000

2 2=00

1 =100

1 =@00

1 1=00

1 4=400

1 1=300



4 3=200

1 300

3 18=000

3 14=400

1 =100

1 =@00

4 24=000

1 1=8001 1=300

1 800

1 300

3 1=300

3 3=000

1 =00

3 2=400

4 8=000

1 =00

1 =000

20 12=000

3 18=0002 13=800

3 3=000

3 3=@00

3 2=400

1 =@00

1 300

1 4=>00

1 =@00

1 4=>00

1 =@00

3 00

1 100=8001 100=800

1 =000

3 1=200

3 24=000

4 3=200

1 =000

1 =100

3 24=000

1 8=000

2 2=00

3 2=400

1 1=3003 2=400

1 =100

1 =@00

1 4=800

2 1=00

2 2=000

3 18=000

2 2=00

2 12=000



1 =400

3 2=400

1 1=300

3 18=000

1 4=>00

2 13=800

4=800

3 3=0001 3=800

2 13=800

2 2=000

4=800

1 =100

1 =@00

4 1=200

10 8=000

1 =100

3 20=>00

1 300

3 1=3002 1>2=000

3 3=@00

3 3=000

3 2=400

2 1=000

2 1=00

3 3=@00

2 2=000

1 300

1 =100

4=000

1 1=3001 1=000

1 800

2 12=200

1 1=300

1 1=000

1 800

1 =100

3 8=400

1 8=000

2 2=00

1 1=000

2 1=001 =100

1 800

1 2=800

1 800

1 =100

2 13=800

2 1>2=000

3 3=@00

2 2=000



3 2=400

1 4=>00

4 3=200

1 =@00

2 4=000

2 1=00

2 4=000

2 1=002 2=00

1 300

1 =100

1 =@00

1 1=00

1 4=400

1 1=300

3 3=000

4=800

3 14=400

3 1@=800

1 3=8001 =800

1 10=00

1 =800

1 =800

1 8=000

1 2=000

2 13=00

3 8=400

1 8=000

3 12=@00

1 2=800

3 =001 8=000

1 =@00

1 4=>00

1 =00

3 3=000

1 300

2 4=400

1 =100

1 =@00

3 18=@00

4=000

1 4=4001 1=00

2 2=00

3 3=000

3 1@=800

1 3=300

3 =@00

1 =@00

2 2=00

2 2=000



1 =@00

2 4=400

1 2=200

1=200

1 =100

1 2=000

1 10=00

4=0002 2=00

4 3=200

1 =100

1 =@00

1 300

1 =00

3 =00

3 2=400

1 8=000

1 2=000

3 2=400

3 1@=8001 3=800

1 800

1 1=300

4 8=800

1 =100

1 =@00

1 1=00

2 8=800

1 1=300

4 3=200

3 30=000

1 3003 1@=800

1 10=00

2 21=200

1 32=00

1 1=000

1 4=>00

1 =@00

4 2>=00

2 13=800

1 1=00

1 1=300

3 3=0003 2=400

1 2=100

1 4=800

3 =00

3 3=@00

2 2=00

3 =00

1 1=300

2 2=000



3 2=400

1 4=800

3 3=@00

3 2=400

1 =800

1 300

3 20=400

1 1=3001 3=800

1 800

1 =100

2 13=800

2 13=00

1 =000

1 1=00

1 4=400

1 1=300

2 4=200

3 14=400

4 4=0004 3=200

1 3=300

3 1@=800

1 4=>00

2 13=800

3 2=400

3 14=400

3 1>4=000

3 3=000

1 300

2 21=200

1 =1001 =400

1 2=100

1 1=300

1 300

1 4=800

1 8=000

1 300

2 10=800

1 =800

2 @=00

2 2=00

2 1=002 13=00

1 =400

2 10=800

3 12=@00

3 1>4=000

2 2=000

3 3=@00

2 1=00

1 300



1 800

1=000

1 =100

1 =@00

1 =800

1 1=00

1 4=400

1 1=3003 3=000

4=000

1 2=100

1 300

3 14=400

3 @=@00

3 24=000

1 10=00

1 4=400

1 =@00

1 4=>00

1 2=2003 =00

4 4=000

4=000

=00

1 1=00

1 4=400

2 2=00

1 2=100

1 =100

1 =@00

2 1=00

1 1=0001 =00

4 8=000

1 1=00

1 2=100

1 2=200

1 =800

2 @=00

1 1=300

3 2=400

1 2=100

1 =400

1 2=1002 1=00

2 2=000

3 24=000

3 2=400

1 =100

1 =@00

1 1=00

1 4=400

1 1=300



3 3=000

3 14=400

4=800

3 1@=800

1 =00

1 =100

2 13=800

1 10=001 8=00

2 11=000

1 4=>00

2 13=800

2 10=800

3 24=000

3 3=000

2 2=00

2 1=00

1 300

1 =00

1 10=002 12=200

1 =@00

3 2=400

1 1=00

2 10=800

2 11=000

2 10=800

1 2=100

3 12=00

1 =00

1 1=300

1 4=>001 =@00

1 4=800

1 2=000

2 2=00

2 2=000

2 1=00

1 300

1 4=>00

1 =@00

2 10=800

2 4=200

3 3=@003 3=000

3 2=400

1 300

3 24=000

10 2=000

2 10=800

3 24=000

3 3=@00

3 2=400



2 >=00

> =00

3 14=400

3 3=000

1 10=000

1 =100

1 4=>00

1 =@001 =400

1 2=100

2 2=00

2 2=000

2 1=00

1 300

1 @=300

1 2=100

2 2=00

3 2=400

2 1=000

1 1=3003 2=400

1 2=100

1 1=300

3 2=400

1 3=800

2 2=00

1 =00

3 1=000

2 2=000

2 1=00

1 =@00

1 8=0003 1=300

1 =@00

1 1=300

3 3=000

1 800

1 4=400

2 13=800

1 =100

3 12=@00

2 2=000

2 13=800

1 4=>002 10=800

1 2=100

2 1=00

2 2=000

1 =400

2 2=00

1 1=000

2 1=00

1 =400



2 2=00

2 10=800

2 1=000

2 2=00

1 1=000

2 1=00

1 2=100

2 10=8002 2=00

1 800

1 2=100

2 @=00

1 1=300

1 1=000

1 800

1 2=100

3 12=@00

2 2=000

2 1=00

2 @=001 1=300

1 1=000

2 1=00

3 =000

3 2=400

1 =400

2 4=000

1 4=800

1 2=000

1 2=100

28=800

=0002 4=200

1 4=>00

1 =@00

4 3=200

1 8=200

1 =100

1 =@00

2 11=000

3 14=400

4 1=200

4 4=000

4 3=2002 2=00

3 2=400

2 10=800

2 2=000

1 1=300

3 3=000

2 1=00

2 10=800

2 2=00



1 2=100

2 4=400

2 10=800

1 2=100

2 1=00

1 =00

1 =100

1 =@001 1=00

1 4=400

> >=000

1 2=100

3 2=400

1 300

3 14=400

3 @=@00

3 1@=800

1 10=00

2 13=800

1 =001 32=00

3 2=400

2 18=200

2 13=800

1 2=000

4=000

1 2=100

1 4=800

1 =100

1 =@00

2 2=00

1 4=400 =000

1 300

1 =100

3 2>=300

3 1>4=000

1 800

3 3=000

1 2=100

3 @00

4 4=000

2 4=200

3=4001 300

2 11=000

2 00

1 300

10 2=000

2 10=800

3 2=400

3 2=400

2 1=00



1 =400

2 10=800

2 2=00

1 32=00

1 4=>00

1 =100

1 =@00

1 =004 3=200

=000

1 4=400

3 24=000

3 14=400

1 300

1 10=00

3 =00

4 2>=00

1 10=00

1 4=>00

2 13=8001 =00

3 3=000

3 3=@00

3 14=400

1 4=800

1 32=00

3 3=000

1 4=>00

2 13=800

2 10=800

1 2=100

3 3=@003 2=400

3 3=000

1 300

1 =@00

1 4=>00

3 12=@00

2 10=800

1 2=100

1 300

3 3=@00

3 3=000

3 2=4001 300

3 1@=800

3 2=400

4=000

2 10=800

2 1=000

2 2=00

2 2=00

2 10=800



3 3=@00

3 =00

3 =000

2 10=800

1 2=100

2 1=00

2 2=000

1 4=>003 2>=300

2 13=800

2 13=800

1 4=800

2 4=000

4=000

1 2=100

4 @=00

1 2=200

2 =00

2 1=00

2 4=4003 =000

2 =00

3 1@=800

2 4=000

2 18=200

4 3=200

3 2=400

2 10=800

1 2=100

2 2=00

2 2=000

3 2=4001 1=300

2 10=800

1 2=100

1 1=300

2 2=000

2 2=400

1 1=300

2 13=800

3 3=000

3 2=400

1 4=>00

3 1@=8004 3=200

1 1=300

4 3=200

3 2=400

1 1=300

2 2=000

2 1=00

1 1=300

2 11=000



1 8=200

2 4=800

2 34=800

1 =100

1 =@00

1 =00

3 14=400

1 3003 @=@00

1 4=400

1 =@00

1 =@00

3 =000

14 2=800

1 10=00

1 10=00

1 10=00

1 103=800

3 1=000

2 11=0001 =@00

1 =@00

1 10=00

1 =100

1 =@00

1 4=400

8 8=000

8 =400

1 =00

2 2=00

3 24=000

1 =1001 =@00

1 32=00

2 1=000

3 24=000

3 24=000

2 1=000

1 2=100

3 24=000

1 2=100

1 =100

1 =@00

4=8004 4=000

1 1=300

1 4=400

2 00

3 24=000

4 3=200

1 800

1 =100

1 =@00



=000

4 8=000

1 300

1 4=400

1 1=300

1 2=100

3 24=000

2 1=001 =100

1 =@00

1 =00

3 3=000

1 2=100

1 1=300

3 24=000

2 1=00

1 =100

4 =200

3 3=000

3 2=4001 2=100

1 300

1 2=200

1 800

1 =400

2 11=00

2 1=000

3 24=000

1 8=000

3 24=000

3 24=000

2 1=0002 2=000

2 1=00

3 =000

1 1=000

1 800

3 24=000

2 2=000

2 1=00

3 24=000

1 1=00

1 4=400

1 =1001 =@00

=000

3 24=000

3 14=400

1 4=400

1 =00

1 1=300

4=000

1 =100



1 =@00

> >=000

1 1=300

1 300

3 14=400

1 4=400

3 24=000

1 4=>001 =@00

1 4=300

2 2=000

3 2=400

3 24=000

1 =@00

1 =@00

1 =100

2 1=00

2 24=00

1 12=300

2 1=001 2=200

2 1=000

2 1=00

2 2=000

3 =000

1 1=000

1 800

1 1=300

1 10=00

2 21=200

1 =100

1 =@001 4=400

=000

8 =400

3 @=@00

1 300

1 2=100

1 =100

1 =@00

1 4=400

=000

8 =400

3 @=@001 300

1 2=100

1 =00

1 4=>00

1 =@00

1 1=300

2 2=000

2 1=000

2 2=000



1 2=100

1 10=00

1 10=00

1 10=00

1 =00

1 4=400

2 4=200

3 3=@003 3=000

4 3=200

1 300

1 800

1 300

1 300

2 10=800

1 300

3 3=@00

3 3=000

3 2=400

1 2=1001 =100

1 =@00

1 4=400

1 1=300

3 14=400

3 3=000

3 2=400

3 @=@00

4 3=200

1 1=300

1 32=00

2 >=003 =000

2 10=800

2 1=000

1 1=300

3 2=400

2 1=000

1 =100

1 =@00

1 2=100

1 =00

3 3=@00

3 3=0003 2=400

1 300

1 10=00

2 1=00

1 =100

1 =@00

1 1=300

1 300

1 4=300



1 3=800

2 1=000

4 3=200

1 2=100

1 4=>00

1 =@00

1 =400

2 2=002 2=000

3 2=400

1 300

1 2=100

1 =00

1 =100

1 =@00

4=000

1 1=300

1 2=100

3 14=100

2 @=003 1=000

1 =100

1 =@00

1 2=100

2 1=00

1 1=300

1 800

1 3=800

3 2=400

1 =00

1 1=300

1 10=001 10=00

1 =100

1 =@00

2 1=00

1 1=300

1 300

1 1=800

3 12=@00

2 1=000

1 800

1

2 1=0002 2=00

1 1=000

2 1=00

1 1=300

2 2=000

3 2=>00

2 2=00

1 1=000

2 1=00



2 3=800

3 =000

3 3=@00

1 1=000

2 1=00

1 =100

1 =@00

4=8001 1=300

1 10=00

1 10=00

4=800

1 1=00

1 4=>00

1 =@00

4=000

2 2=000

1 4=>00

2 13=800

4 4=0004 4=800

4 =200

2 1=000

10 =000

14 >=000

1 =100

1 =@00

1 4=400

2 2=00

4=000

3 3=000

1 2=1001 2=200

1 =@00

1 =100

2 4=000

1 4=400

1 1=300

3 3=000

1 2=100

4=000

2 10=800

1 1=300

1 1=0002 1=00

1 2=100

1 4=300

2 1=000

2 2=000

1 800

2 1=00

4 20=400

1 =400



2 2=00

1 2=100

2 1=000

1 1=300

2 2=000

2 1=00

2 @=00

2 3=2002 2=00

1 1=000

2 800

1 2=100

2 1=000

1 4=>00

1 =@00

1 2=100

1 =400

1 8=000

2 2=000

3 3=@002 1=000

2 2=00

1 =@00

1 =400

2 1=000

2 1=000

1 4=400

1 1=300

1 2=100

1 =@00

1 =100

1 4=>002 13=800

3 2=400

1 2=100

1 1=300

1 =00

1 10=00

1 800

1 300

1 4=>00

2 3=200

4 32=000

4 3=2002 4=400

4=000

4 1@=200

3 1@=800

1 =@00

3 3=000

1 =00

1 2=100

1 =400



2 1=000

1 1=300

1 1=000

2 1=00

2 3=200

2 10=800

2 2=00

1 1=0001 800

2 1=000

1 1=000

1 800

2 10=800

2 2=00

2 2=000

1 800

2 1=00

724,100 7,300,800 2,778,100 10=803=000

1403400 2000

1288800 1203200

13404>00 4@@400

4004@00 1142>00































































44000 14@02@00

1@84>00 1180>300

4802100 13>2000

111@2300 40282200


















4/1/2014 Ny.JAMI7A; MM

Ny.Binti BPJS DINAS

4/3/2014 Ny S'tarni BPJS MM

An Sa-itri Dwi BPJS DINASAn Mir9a BPJS DINAS

4/4/2014 An. ?a+i BPJS DINAS

4/13/2014 An. M. ?a--an BPJS DINAS

4/14/2014 Ny. Erna MM

Tn.Sii+ BPJS DINAS

Ny P'(i BPJS DINAS

Ny Al)ira BPJS MM

4/1>/2014 Tn Awana BPJS DINAS

4/23/2014 Tn. S'!en! MM

4/28/2014 POLI BEDA; 3 6A: STOP *;O*$

TOTAL



NAMA OBAT JMLA;

;A7GA PASIEN


Si)#atatin 10 3=000

*e-ar"il 10 8=000

*anerartan 8 )! 30 240=000

7eli#an 1 =007eli#an 2 11=000

*lina)i%in 10 10 =000

7eli#an 1 =00

S,'it 3% 1 800

Onan%etr"n Ta @=000

Met-"r)in 30 =000

E%li 0 )! 40 48=000

7anitiinne ta 10 2=000

7anitiinne ta 10 2=000

5* 18 1 1=00

A&'a In( 1 2=100

1 2=@00

55,500 242,000 91,800 38@=300

10803000

11=1@2=300



TANGGAL NAMA PASIEN BPJS GOLONGAN NAMA OBAT JMLA;

/1/2014 Ny. Siti *"li-a BPJS MM In-'et ara 1

i# 18 1

S,'it 10%% 2

rinea! 1

S,'it %% 3A&'a 1

S,'it 3%%

Tra)a"l in( 3

Neele 23 1

Ny. B'iyani MM Antrain in( 3

Ny. Siti Eni BPJS MM In-'et ara 1

i# 18 2

rinea! 1

S,'it 10%% 1

S,'it %% 3S,'it 3%%

Neele 23 1

A&'a 1

Tra)a"l in( 3

Ny. T'ti+ S'il"wati MM Antrain in( 3

By. Ny. B'iyani MM M'%' 1

By. Ny. Siti Eni BPJS MM M'%' 1

By. Ny. Siti *"li-a B BPJS MM M'%' 1

By. Ny. Siti *"li-a A BPJS MM M'%' 1

Ny.Ja)iat'n BPJS MM In-' Biaa 1

I# 20 1

*e-tria"n 2

A&'a 1

Onan%etr"n 2

S,'it 10 2

S,'it 2

S,'it 3 2

Nele 2 1

An.Al)ira BPJS MM In-' Biaa 1

D4 1/4 2

N: Sar)i BPJS MM *e-tria"n 1

S,'it 10%% 2

S,'it 3%% 2

A&'a 1

neele 2 1

An Al)ira BPJS MM *e-tria"n 2

A&'a 2

S,'it 10%% 2



S,'it 3%% 3

Neele 2 1

Ny :'ni BPJS MM Neele 23 1

S,'it 3%% 1

Ny. :'lity"wati BPJS MM I# 22 1

Ny. Ja)iat'n BPJS MM *e-tria"n 2

S,'it 10%% 2 Ny. Dwi BPJS MM *e-"tai)e In( 2

Genta)i%in In( 2

A&'a 1

S,'it 10%% 2

Ny. Sar)i BPJS MM *e-tria"n 1

S,'it 3%% 2

An. Al)ira BPJS MM *e-tria"n 1

S,'it 3%% 2

An. Ael MM *e-tria"n 1

S,'it 3%% 4A&'a 1

/2/2014 Tn Ma'!i BPJS MM Selan! "2 w 1

S,'it 10%% 2

S,'it %% 2

rinea! 1

A&'a 1

Ny J',riyat'n BPJS MM *e-"tai)e In( 2

S,'it 10%% 3

S,'it %% 3

S,'it 3%% 3

In-'et ara 1

I# 20 1

Neele 2 1

D7 G't")" BPJS MM *e-"tai)e In( 2

S,'it 10%% 3

S,'it %% 3

S,'it 3%% 3

Neele 2 1

N: 6a+iya BPJS MM In-'et ara 1

i# 18 1

S,'it 3%% 2

SDr. G't")" BPJS MM *e-tria"n 2

O)e,ra9"le In( 1

Antrain in( 3

Neele 2 1

An. Irai) MM Antrain in( 2

Ny. J',riat'n BPJS MM *e-"tai)e In( 2

S,'it 3%% 1



Ny. Sar)i BPJS MM *e-tria"n 1

S,'it 3%% 2

A&'a 1

Tn. Ma'&i BPJS MM *e-tria"n 2

DEA In( 4

S,'it 3%% 2

/3/2014 Ny. Enny S. BPJS Dina In-'et ara 1S'r-l" 18 1

rina! 1

S,'it %% 3

S,'it 10 %% 1

S,'it 3%% 6

Neele 23 1

Tra)a"l in( 3

Ny. 6iwi+ S. BPJS Dina In-'et ara 1

S'r-l" 18 1

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S,'it %% 3

S,'it 10 %% 1

S,'it 3%% 6

Neele 23 1

Tra)a"l in( 3

Tn. S'+a)t" BPJS Dina *e-tri in( 2

A&'a 2

In-'et ara 1

Antrain in( 2

S,'it 10 %% 3

S,'it %% 3

S,'it 3%% 3

Neele 2 1

By. Ny. 6a+i(a BPJS MM M'%' 1

By. Ny.6iwi+ BPJS Dina M'%' 1

By. Ny. Enny BPJS Dina M'%' 1

Ny.7',iati BPJS MM I# 18 1

5'r"e)i In( 1

S,'it 3 4S,'it %% 4

Aa) trane 3

Ny.Mar)i BPJS UMUM rina! 2

S,'it 10 %% 1

S,'it %% 4

S,'it 3 4

*e-tri 4



A&'a 1

Ny.J',riyat'n BPJS MM ia9"l in- 3

S,'it 3 3

Tn S'+a)t" BPJS Dina *e-tri 1

S,'it 3%% 3

aantraain in( 3

Tn Ma'!i BPJS MM *e-tri 2

Dea in( 4

*LOP7AMEL INJ 3

S,'it 10 %% 2

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S,'it 3%% 3

Ny Sar)i BPJS MM *e-tri 1

S,'it 10% 1

S,'it 3%% 2

A&'a 1

N: J',riat'n BPJS MM *e-" 2

*LOP7AMEL INJ 3

S,'it 10%% 2

S,'it 3%% 2

A&'a 1

/4/2014 Ny. Inrawati MM Antrain in( 3

Ny Marmi BPJS UMUM diazol inf 5

needle 23 3

ceftri 2

Spuit 3cc 2Spuit 5cc 2

Tn S'+a)t" BPJS Dinas Ceftri 2

Antrain in 3

A!ua 1

spuit 1"c 3

N> J&.riat&n BPJS UMUM Cefo 1

diazol inf 3

C#$P%AM&# '(J 1

Tn Ma'!i BPJS UMUM C&)tri in 2

C#$P%AM&# '(J 1Spuit 3cc 5

Ny i!i UMUM Antrain in 2

//2014 ny. J'wari BPJS UMUM Selan* o2 d+s 1

'nfuset dara, 1

i- 1. 1

Ny. S'art'ti+ BPJS UMUM i- 1. 1

'nfuset dara, 1



Mucus 1

Tn.Ma'+&i BPJS UMUM Ceftri 2

D&/A 'n 2

Spuit 1" 2

Spuit 3 3

A!ua 1

Tn.S'+a)t" BPJS UMUM Antrain in 3

Ny.J',riyat'n BPJS UMUM Ceftri 2

diazol inf 2

Spuit 1" 1

Spuit 3 3

A!ua 1

//2014 Tn. $a)ani UMUM Antrain in 2

Ny. Mar)i BPJS UMUM Spuit 5cc 1

Spuit 3cc 1

An. 7ayan'n BPJS Dinas 'nfuset 0iasa 1

i- 22 1

Spuit 5cc 2

Spuit 3cc 2

Cefotaie 'n 1

A!ua 1

Dea in 1

Spuit 1"cc 2

pct sr 1

needle 25 1

Tn. S'+a)t" BPJS Dinas 'nfuset dara, 1 Ny. S'%iati BPJS UMUM Alodipin 5 * 5

Captopril 25 2

ny. I+a BPJS UMUM 'nfuset dara, 1

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N> 'Iti J&aia( BPJS UMUM Mucus 1

Spuit 5cc 4

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B ( 'a BPJS UMUM Mucus 1

7n Masru BPJS UMUM Cefotaie 'n 3'- 2" 1

Spuit 1"cc 1

Spuit 5cc 3

(eedle 25 1

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Spuit 3cc 2

Tn. MAS'!i BPJS UMUM Spuit 1"cc 1



Sr. Aan BPJS UMUM Antrain in 3

Spuit 3cc 1

Tn. )Ar'n BPJS UMUM Antrain in 3

Spuit 1"cc 1

Spuit 5cc 2

Spuit 3cc 1

7n %ADini UMUM #e-ofloacin 1

7n 8asani UMUM Antrain in 1

( Suiati UMUM Antrain in 3

/8/2014 n 'a BPJS UMUM )uroseid 'n 1

( Siti 9ulaia, BPJS UMUM )uroseid 'n 1

Sdr Aan BPJS UMUM )uroseid 'n 2

7n MAsdu!i BPJS UMUM Si-astatin 1"M* 3

Sdr Aan BPJS UMUM Antrain in 3

Spuit 1"cc 2

7n MASdu*i BPJS UMUM Spuit 5cc 2

Sspuit 3cc 2

tn (ur aadi BPJS UMUM Spuit 5cc 1

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( Ani BPJS UMUM Antrain in 2

Spuit 1"cc 2

Spuit 5cc 1

Spuit 3cc 1

( Suciati BPJS UMUM i- 1. 1

7raadol in 1

Spuit 3cc 1"Urine0a* 1

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7n Suato BPJS Dinas Antrain in 2

/@/2014 SdrMustain BPJS UMUM Spuit 3 3

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B&ti Uu Mucus 1N> &%a BPJS UMUM Selan* o2 d+s 1

i- 1. 1

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spuit 1"cc 1

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7raadol in 1

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Spuit 3cc :

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B ( Juliani uu Mucus 1

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aantraain in 3

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tn (ur aadi BPJS UMUM Cipro 'nf 1

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( 8ursiati BPJS UMUM Spuit 3cc 2

/10/2014 By Sa%itri BPJS UMUM ;icilin 2

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spuit 1"cc 1

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7n (urai BPJS UMUM Cipro 'nf 2

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/11/2014 tn Suato BPJS Dinas udopa 2

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B ( (*uoin UMUM Ca *luconas 1

B ( C,aeri UMUM Ca *luconas 1B ( Juriati BPJS Dinas Mucus 1

nntiti BPJS UMUM entaicin 'n 2

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cefo 3

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Tn Sardi BPJS Dinas )uroseid 'n 1"

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7n (u%AJ' BPJS UMUM Cipro inf 2

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spuit 1"c 1

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4/12/2014 Sdr Aan BPJS UMUM Spuit 1" cc 2

Spuit 5 cc 2

Spuit 3 cc 2

7n Sardi BPJS UMUM Spuit 3 cc 3

B> Ny Tri : BPJS UMUM Mucus 1

( Juriati BPJS UMUM '- 1. 1( 7iti BPJS UMUM Ceftriaon 2

(eedle 25 1

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Cefotaie 'n 3

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$eprazole 'n 2

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7nSardi BPJS UMUM spuit 1" 2

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7nMuito Uu Antrain in 2

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nntiti BPJS UMUM -entolin 3

Ceftriaon 1

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spuit 1" 1

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spuit 3 cc 3

*eftria&$n 2

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3 36000

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3 36000

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312500 1361106B00 1644B6300 148=2=00



TANGGAL GOLONGAN NAMA OBAT JMLA;

5/28/2014 -n Nayla >mum +$mperi$ne yr 1

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#/2=/2014 Tn. abran" - -ml$ipin 5 (" 30

#/28/2014 <*> >+- 5

NAMA PASIENBPJS



;A7GA PASIEN

MM BPJS MM BPJS DINAS ;-R?

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1561586B00




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y.etyarini >(>( erytr$micin 250 1

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;A7GA PASIEN


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;A7GA PASIEN


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JMLA;

;A7GA PASIEN


2 526800

5 116000

1 #6B00

2 5268002 =6#00

4 2B6#00

4 36200

2 106800

2 526800

2 26#00

3 26400

1 156500

1 46400

1 16300

3 36000

3 1#6200

1 800

1 #6=00

1 #6B00

3 1B6800

1 #6500

8 #6400

1 #6#00

1 46000

2 106800

2 26#00

3 26400

1 #6B00

2 526800

2 =6#00

4 2B6#00

2 26#00

2 26000

2 106800

2 5268001 16300

3 26400

1 #6=00

1 #6B00

2 16#00

1 #6=00

1 #6B00



1 156500

1 46400

1 16300

3 36000

= 56#00

1 300

1 363003 246000

3 1#6200

4 216#00

2 136800

1 106#00

10 116000

1 16000

1 800

1 106#00

1 #6B001 46=00

3 36B00

# #6000

5 46000

1 #6500

4 326000

4 156200

1 156500

1 46400

1 46000

1 #6B00

2 186200

2 =6#00

2 16#00

2 106800

1 300

2 26#00

1 16000

2 16#00

1 564002 26#00

1 16000

2 16#00

1 46=00

2 136800

2 =6#00

2 1#6000



2 106800

3 26400

3 36000

3 36B00

1 #6=00

1 #6B00

1 156500

1 46400

1 16300

3 36000

5 46000

3 246000

1 36300

1 300

3 1#6200

1 #6=00

1 #6=00

1 #6B00

1 156500

1 46400

1 16300

3 36000

5 46000

1 300

3 1#6200

3 2460001 36300

10 B36000

8 46000

1 326#00

1 106#00

1 106#00

1 #6B00

1 #6000

2 =6#00

2 16#002 106800

2 26#00

3 26400

1 #6B00

1 #6=00

1 46400

1 156500

1 16300



# 46800

1 36300

3 246000

1 300

3 1#6200

3 36000

2 1068002 =6#00

3 246000

3 36B00

1 106#00

2 106800

1 #6=00

3 26400

3 36000

1 #6B00

3 36B003 246000

1 300

1 #6=00

2 =6#00

1 #6=00

1 #6B00

2 26000

1 46400

1 56400

1 156500

1 36300

3 246000

1 #6500

1 #6500

1 46=00

1 #6B00

2 1#6000

2 46000

1 36800

2 26#00

2 26000

4 36200

1 56400

2 =6#00

2 1#6000

2 86#00

3 26400

1 16000



3 246000

2 =6#00

3 126B00

# 306#00

3 1#6200

2 26000

3 1B68003 126B00

2 106800

2 =6#00

1 #6=00

1 26200

1 800

3 B6B00

4 326000

2 16#00

3 1#62003 106800

5 46000

3 106800

1 #6=00

1 #6B00

2 26#00

2 #00

1 #6500

3 1#6200

3 36000

8 #6400

3 246000

1 36300

1 16300

1 800

2 =6#00

2 106800

2 =6#00

3 246000

3 36B00

2 106800

2 26#00

1 #6=00

1 #6B00

4 216#00

4 46000

1 300

1 46=00



2 #6#00

1 26000

3 26400

3 36000

1 300

1 #6=00

1 #6B001 156500

1 46400

1 16300

3 36000

5 46000

3 1#6200

1 #6500

5 46000

3 36000

1 163001 #6=00

1 #6B00

1 156500

1 46400

3 1#6200

1 106#00

1 106#00

1 #6B00

1 #6=00

2 106800

3 #6#00

2 =6#00

1 16000

5 46000

1 #6500

1 156500

1 46400

5 246000

2 16#00

2 16#00

1 56400

2 106200

1 46300

2 1#6000

3 106800

3 26400

2 26000

2 106800



3 246000

2 26000

2 526800

2 =6#00

2 16#00

2 26000

1 #6#001 46=00

2 186200

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3 26400

1 #6B00

4 1056#00

5 26000

3 2=6300

1 8003 246000

2 106200

2 106800

2 26000

1 #6B00

1 46=00

3 36B00

3 36000

3 26400

1 300

2 106800

2 106800

3 246000

2 26000

2 26#00

2 16#00

2 =6#00

4 36200

10 B6000

3 246000

2 26#00

2 16#00

1 86000

1 16000

3 1#6200

2 86#00

3 246000

1 36800



3 36B00

2 26000

1 #6=00

1 #6B00

1 56400

1 16000

1 8002 #00

10 56000

1 4=6000

1 #6B00

5 46000

5 56000

5 #6500

2 =6#00

1 300

10 460001 106#00

1 106#00

1 #6=00

1 #6B00

1 156500

1 46400

1 16300

3 36000

2 106800

8 #6400

3 246000

3 B6B00

2 #00

3 16200

1 #6B00

1 #6=00

1 156500

1 46400

1 16300

3 B6B00

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3 26400

3 36000

2 #00

3 36000

1 800

2 46000

1 26200



1 800

1 #6=00

1 #6B00

3 26400

1 16300

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3 246000

3 #6000

1 16300

2 =6#00

1 800

2 =6#00

1 #6B00

1 #6B00

5 =60002 186200

5 46000

2 186200

2 526800

1 #6#00

1 46=00

1 #6#00

2 26#00

1 16000

3 26400

1 #6B00

1 46=00

3 246000

1 16000

3 26400

1 46=00

1 #6B00

3 26400

4 36200

1 36300

1 #6=00

1 #6B00

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3 246000

2 46000

1 #6500

1 156500

1 46400



1 16300

3 36000

1 300

1 106#00

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2 86#002 26#00

2 26000

2 16#00

1 156500

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1 M #6=00

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2 106800

2 26#00

2 16#001 300

2 106800

3 246000

1 26200

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2 26#00

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2 =6#00

3 26400

2 526800

3 #6#00

2 =6#00

3 26400

2 106800

5 46000

5 56000

5 #6500

1 46=00

1 300

1 #6B00

5 2=6000

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4 56200

2 26000

5 46000

4 86000

1 300

2 1#6000



2 16#00

2 106800

2 26#00

2 16#00

1 1006800

3 26400

2 #6B001 #6=00

3 1B6800

2 106800

3 #6000

2 26#00

2 26000

2 16#00

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1 16300

2 260001 800

2 186200

3 26400

1 #6500

2 106800

1 16300

1 16000

1 800

1 #6#00

2 106800

2 26#00

1 16000

1 800

1 #6=00

1 #6B00

2 316000

3 36B00

1 16000

2 46000

= 56#00

1 #6=00

1 #6B00

1 #6B00

= 56#00

1 16300

1 106#00

1 106#00

1 16300



2 16#00

2 26#00

2 106800

3 246000

1 300

3 26400

1 #6=002 16#00

1 16300

1 16000

1 800

1 16300

1 16000

1 800

2 106800

1 16300

1 160001 800

1 16300

1 16000

1 800

2 106800

3 36B00

2 106800

1 #6=00

1 #6B00

= 56#00

1 156500

1 46400

1 16300

3 36000

3 1B6800

1 36300

1 #6B00

1 #6=00

2 26#00

1 16000

1 300

1 #6#00

1 46=00

4 36200

1 56400

2 #6B00

2 #6#00

2 #6B00



1 #6B00

2 16#00

1 106#00

1 #6=00

1 #6B00

1 26=00

5 460005 26000

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1 300

3 246000

3 156000

2 16#00

2 106800

2 26#00

2 16#00

3 264003 246000

2 106800

3 1#6200

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3 246000

3 36B00

1 #6B00

1 #6=00

3 36B00

3 36000

5 46000

1 300

1 56400

1 46=00

1 #6=00

1 #6B00

1 156500

1 46400

1 16300

3 36000

8 #6400

3 1#6200

1 36300

3 246000

1 #6B00

1 #6=00

1 800

1 16300



2 16#00

2 526800

2 106800

1 16000

1 #6=00

1 #6B00

1 1565001 46400

2 26#00

1 #6500

8 #6400

3 36000

3 1B6800

3 1#6200

1 46=00

3 36B00

3 360003 26400

1 300

2 106800

2 526800

1 106000

1 56400

1 106#00

1 106#00

1 106#00

1 #6=00

1 #6B00

3 26400

4 86000

1 #6=00

1 #6B00

1 156500

1 46400

1 16300

3 36000

5 46000

1 300

1 36300

3 1B6800

3 1#6200

1 #6B00

1 #6=00

1 16300

3 36000



5 46000

3 B6B00

3 1B6800

3 1#6200

1 300

1 156500

1 464001 156500

1 46400

1 16300

3 36000

5 46000

1 300

1 36300

3 1B6800

3 1#6200

2 460001 800

1 106#00

1 16000

1 106#00

1 16000

1 106#00

1 16000

2 =6#00

2 16#00

2 526800

2 16#00

1 156500

1 46400

3 36000

3 1#6200

5 46000

3 1B6800

1 36300

1 16300

1 106#00

1 106#00

1 106#00

1 106#00

1 #6B00

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2 46000

1 156500

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2 26#00

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3 36000

3 1#6200

1 36300

2 106800

2 =6#001 16300

2 26000

1 800

2 =6#00

1 16000

1 800

1 #6=00

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1 156500

1 464004 86000

1 56400

1 16000

4 36200

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1 1006800

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1 156500

1 46400

1 16300

5 46000

3 36000

3 1#6200

1 300

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1 #6500

1 16300

2 16#00

1 #6B00

1 46=00

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2 106800

3 36000

2 =6#00



1 #6=00

2 136800

1 156500

1 46400

1 16300

3 36000

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= 56#00

3 1#6200

1 36300

1 #6B00

1 46=00

2 =6#00

2 1#6000

1 16300

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1 300

1 #6=00

1 #6B00

1 56400

2 1#6000

2 26#00

3 26400

1 56400

2 1#6000

2 26#00

3 26400

3 26400

1 #6=00

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1 #6500

1 16300

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1 46=00

1 #6B00

1 #6500

2 106800

2 =6#00

5 #6500

2 26000

5 46000

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10 116000

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5 56000

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3 246000

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1 46=00

3 26400

2 26000

2 106800

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2 26#00

1 160001 800

1 16300

2 26000

1 800

1 26500

1 16300

1 16000

1 800

1 56400

2 1#6000

1 16300

1 16000

1 800

3 246000

1 16300

1 16000

2 16#00

5 16500

1 #6=00

2 136800

1 156500

1 46400

1 16300

3 36000

= 56#00

3 1#6200

1 36300

3 1B6800



1 106#00

1 106#00

1 #6=00

2 136800

1 #6500

1 156500

1 464003 36B00

3 36000

3 26400

1 300

2 106800

2 1#6000

1 1006800

1 1006800

1 156500

1 464005 56500

1 #6500

3 26400

3 26400

4 206400

4 2#6400

3 36B00

1 56400

1 8#6000

2 1#6000

1 16300

1 16000

1 800

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2 26000

1 800

2 26000

1 800

4 56200

1 56400

1 16300

1 16000

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3 246000

1 46=00

1 326#00

1 56400

2 1#6000



3 #6000

2 26#00

2 26000

1 800

1 326#00

2 46000

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1 106#00

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1 16300

1 16000

3 26400

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1 16300

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3 1#6200

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1 #6500

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2 26000

4 36200

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H 1463336=00 261306500




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JMLA;

;A7GA PASIEN


1 16300

4 16200

1 46500

5 1600010 56000

1 800

5 36000

30 #6000

11 56500

15 46500

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10 5600010 46000

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1 16000

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H B36200 4516B00



TANGGAL NAMA PASIEN BPJS NAMA OBAT JMLA; ;A7GA

B/1/2014 y6!$Ayatun puit 10cc 1 1300

NyS(o%iyat&n elan" 2 9s 1 #500

Infus ara! 1 4=00

I 18 1 #B00

puit 3cc 1 800puit 10cc 1 1300

Neele 23 1 300

AnA(mada Iv 22 2 13800

puit 3cc 1 800

-n. ali! iv 22 1 #B00

Infuset biasa 1 4=00

puit 3cc 3 2400

-n. an""i *ef$ta&ime In% 3 1#200

Ny. +ia! I *at! 20 1 #B00

I *at! 22 1 #B00


puit 5 cc 3 3000

puit 3 cc 3 2400

elan" 2 9s 1 #500

Ny. Tri -ntrain In% 3 24000

puit 5 cc 3 3000

B/2/2014 Ny. aaa! Iv 20 1 #B00

Infuset +ara! 1 #=00

puit 10cc 3 3B00

puit 5 cc 3 3000

puit 3cc 3 2400


Ranitiin in% 2 =#00

-ntrain In% 2 1#000

Tn <asan Infuset +ara! 1 #=00

Iv 20 1 #B00

puit 10cc 3 3B00

spuit 5c 3 3000

puit 3cc 3 2400

Neele 25 1 300

Ranitiin in% 2 =#00

elan" 2 9s 1 #500

-n ima *eftria&$ne In% 2 10800

puit 3cc 3 2400

spuit 5c 2 2000

+e&a 1 2000

ny aaa! 40 2 4800

puit 10cc 1 1300

Ny. abina! arsi& in% 10 23000

-n. ima *eftria&$ne In% 2 10800

Ny. aaaa! *eftria&$ne In% 2 10800



Ranitiin in% 2 =#00

puit 10cc 2 2#00

Ny.ttri -ntrain In% 3 24000

puit 5cc 3 3000

Ny. +ya! puit 3cc 3 2400

Tn <asan Ranitiin in% 2 =#00

puit 3cc 4 3200B/3/2014 Nn. itr$! Infuset +ara! 1 #=00

Iv 20 1 #B00

*ef$ta&ime In% 2 10800

puit 10cc 2 2#00

Neele 25 1 300

Ny. ?na! Iv 18 1 #B00


c 1# 1 15500

>RIneba" 1 4400

puit 10cc 1 1300

puit 5cc 2 2000

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puit 3cc 8 #400

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-n. -!maa Infuset biasa 1 4=00

puit 3cc 3 2400

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I 18 1 #B00

c 1# 1 15500

>RIneba" 1 4400

puit 10cc 1 1300

puit 5cc 3 3000

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puit 3cc = 5#00

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Neele 23 1 300

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puit 10cc 3 3B00

Tn.u)ran *a luc$nas 2 20000



puit 10 2 2#00

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puit 10cc 2 2#00

puit 5cc 2 2000

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puit 10cc 2 2#00

puit 3cc 2 1#00

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puit 3cc 4 3200

Ny. Nur -ini puit 5 cc 1 1000

puit 10 cc 1 1300

elan" 2 9s 1 #500

Ny. +ia! puit 3cc 4 3200

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puit 3cc 3 2400

puit 10cc 1 1300

Tn. a)iman urC$ 20 1 #B00

puit 3 cc 4 3200

puit 5 cc 2 2000


B/5/2014 Ny6u9anti I 20 1 #B00

Tn.<asan I 18 1 #B00

Ny:atna +e&a in% 2 4000

puit 3cc 3 2400

Infus ara! 1 #=00

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Ny. Rupia! puit 3 cc 2 1#00

puit 10 cc 1 1300

Tn. <asan Infuset +ara! 1 #=00

Tn. (unasir Iv 20 1 #B00


puit 5cc 1 1000

+i"$&in Tab 5 1000

Ny +9i Ra!ayu Infuset +ara! 1 #=00

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puit 10cc 2 2#00

puit 3cc 2 1#00

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Tn M&na'ir *eftria&$ne In% 3 1#200

puit 5cc 3 3000



Neele 25 1 300

Tn A,d& M&(aimin I 20 1 #B00

lu" 1 8200


puit 3cc 3 2400

spuit 5cc 2 2000

puit 10cc 3 3B00Neele 25 1 300

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puit 5 cc 1 1000

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puit 10 cc 2 2#00

puit 3 cc 4 3200

Ny. +ya! puit 3 cc 4 3200


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puit 10 cc 2 2#00

puit 3 cc 3 2400

Tn. (unasir *eftria&$ne In% 2 10800

puit 10 cc 2 2#00

Ny. a)iman puit 3 cc 3 2400

Tn. <asan puit 3 cc 3 2400

Ny. +9i *ef$ta&ime In% 3 1#200

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puit 10 cc 4 5200

B/#/2014 An I@A *efar$&il cap = 5#00

Tn a)man -ml$ipin 10 5 5500

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c 1# 1 15500

>RIneba" 1 4400

puit 10cc 1 1300

spuit 5cc 3 3000

puit 3cc 5 4000

Neele 23 1 300

Trama$l In% 1 3300

-ntrain In% 3 24000


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(ucus e& 1 10#00

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(ucus e& 1 10#00

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emAbr$,il 300 5 2000

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pir$n$lact$n 5 2500

Tn. (unasir ur$semie In% 2 4400Inf 3@-y elan" 1 32#00


Ny. +9i -ntrain In% 3 24000



puit 3cc 1 800

puit 5cc 2 2000

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I 18 1 #B00

c 1# 1 15500

>RIneba" 1 4400

puit 5cc 3 3000

puit 3cc 5 4000

Neele 23 1 300

puit 10cc 1 1300

Trama$l In% 1 3300

-ntrain In% 3 24000


-n atria Infuset biasa 1 4=00

iv 22 2 #B00

puit 3cc 1 800

N> 6itri nUr I 18 1 #B00


c 1# 1 15500

>RIneba" 1 4400

puit 10cc 1 1300

-ntrain In% 3 24000

puit 3cc 4 3200

spuit 5c 4 4000


-n atria puit 3cc 3 2400

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Iv 18 1 #B00

spuit 10 1 1300

puit 3 cc 3 2400

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Ny. +9i lu" 1 8200

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Tn. a)iman puit 3cc 2 1#00

8/B/2014 y. Ny. Nila (ucus e& 1 10#00

Tn. apuan Infuset biasa 1 4=00



puit 3cc 2 1#00

puit 5cc 2 2000

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Iv 20 1 #B00

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puit 5cc 1 1000

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Tn. (una%ir ur$semie In% 2 4400

puit 5 cc 2 2000

?/?/2014Ny.umiati urC$ 20 1 #B00

surC$ 18 1 #B00

ifus ara! 1 #=00

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r. a!rul Infuset +ara! 1 #=00

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puit 5cc 3 3000

puit 3cc 5 4000

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Ranitiin in% 1 3#00

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Tn. @an!ari +i"$&in Tab 5 1000

Tn. apuan mepra,$le 2 1=2000

puit 10 cc 1 1300

Tn. (una%ir puit 10 cc 2 2#00

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-ntrain In% 3 24000

mepra,$le 2 1=2000

puit 10 cc 2 2#00

puit 5 cc 2 2000

puit 3 cc 2 1#00

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Iv *at! 18 1 #B00

c 1# 1 15500

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spuit 10 cc 3 2B00



Ny. etri)a elan" 2 9s 1 #500

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I *-T< 18 1 #B00


puit 3 cc # 4800

Neele 23 2 #00

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spuit 10 cc 2 2#00

puit 5 cc 2 2000

Ny. 7uliasi! elan" 2 9s 1 #500

puit 3 cc 3 2400

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puit 10 cc 2 2#00

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puit 3 cc 3 2400

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surC$ 18 1 #B00

puit 10cc 1 1300


c 1# 1 15500

>RIneba" 1 4400

Trama$l In% 1 3300

puit 3cc 8 #400

puit 5c 3 3000

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puit 10cc 1 1300

puit 5c 3 3000


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puit 3cc 8 #400



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puit 5 cc 2 2000

puit 3 cc 2 1#00

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mepra,$le 3 258000

puit 10 cc 3 3B00


puit 10 cc 1 1300

puit 3 cc 3 2400

Tn. apuan puit 10 cc 2 2#00

puit 3 cc 4 3200

Ny. a%iyem mepra,$le 1 8#000

puit 10 cc 1 1300

puit 3 cc 3 2400

B/11/2014 By Ny Na'riati (ucus e& 1 10#00

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puit 10cc 1 1300

Tn. apuan mepra,$le 10

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iv 118 1 #B00


c 1# 1 15500

>RIneba" 1 4400

puit 10cc 1 1300

puit 5cc 3 3000

puit 3cc 8 #400

Trama$l In% 1 3300


Neele 23 1 300

Ny. umiati +e&a in% 4 8000

puit 3cc # 4800

elan" 2 9s 1 #500


Trama$l In% 1 3300


Neele 23 1 300




Iv 18 1 #B00

c 1# 1 15500

>RIneba" 1 4400

spuit 10cc 1 1300

puit 5cc 3 3000

Tn. ii) iv 20 1 #B00Infuset biasa 1 4=00

Infusst ara! 1 #=00


ur$semie In% 2 4400

Ranitiin in% 2 =#00

puit 10cc 2 2#00

puit 5cc 2 2000

puit 3cc 2 1#00

+5 1/2 1 B100

*apt$pril 25 10 2000

-ml$ipin 10 m" 5 5500

-ll$purin$l 5 1000

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Neele 25 1 300

Ranitiin tab 10 2000

Tn. ii' ur$semie In% 2 4400

Ranitiin in% 2 =#00

Ny. a%iyem mepra,$le 1 8#000

puit 3cc 2 1#00


r. <enri) puit 10cc 1 1300

puit 3cc 2 1#00

B/12/2014 ByS&miati A (ucus e& 1 10#00

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(ucus e& 1 10#00

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Ny Dya( +e&a in% 4 8000

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puit 3cc 5 4000

Ny u%i !ari I 20 1 #B00


puit 3cc 3 2400

N> Maria( puit 10cc 3 3B00

puit 3cc 3 2400

I 20 1 #B00

Neele 25 1 300

-ntrain In% 2 1#000

c 1# 1 15500

>RIneba" 1 4400

N> Maria( *a luc$nas 1 10000

puit 10cc 1 1300

ByS&miati B



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Ny. (arlia! -ntrain In% 3 24000

puit 5 cc 1 1000

Tn. u%i!ari puit 5 cc 2 2000

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puit 5 cc 1 1000


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puit 5 cc 1 1000

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Neele 23 1 300

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puit 5cc 2 2000

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puit 3cc 1 800

(ucus e& 1 10#00

Ny. iti au,iya! +e&a in% 2 4000

puit 3cc B =200


Iv 18 1 #B00

Trama$l In% 1 3300

-ntrain In% 3 24000

c 1# 1 15500

>RIneba" 1 4400

puit 10cc 1 1300

puit 5cc 3 2400


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puit 10cc 1 1300

Ny. ri u%i -ntrain In% 1 8000

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puit 5cc 5 5000

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mepra,$le 3 258000


puit 10cc 2 2#00

elan" 2 9s 1 #500

TNM&na'ir ur$semie In% 1 2200


spuit 10cc 2 2#00

puit 3cc 1 800

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Lev$C$&acin Inf 1 =8000

spuit 10cc 2 2#00



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puit 10cc 3 3B00

spuit 5cc 3 3000

puit 3cc 3 2400

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puit 5cc 1 1000

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N>Sri P&!i puit 3cc 4 3200

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puit 5cc 2 2000

puit 10cc 1 1300

puit 3cc 1 800

TNA-&' *eftria&$ne In% 2 10800

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puit 10cc 3 3B00

TnM&na'ir ur$semie In% 1 2200


puit 5cc 2 2000

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puit 3cc # 4800

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Trama$l In% 1 3300


puit 5cc 3 3000

puit 10cc 1 1300

c 1# 1 15500

>RIneba" 1 4400



Neele 23 1 300

Ny.-nti I 20 1 #B00

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mepra,$le 1 8#00

puit 10cc 5 #500puit 3cc 8 #400

puit 5cc 5 5000

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Ny. eni Neele 25 1 300

puit 3 cc 5 4000

puit 5 cc 5 5000

puit 10 cc 5 #500

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Tn. -"us +40: 2 4800

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puit 10cc 3 3B00

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puit 5cc 2 2000

puit 3cc 2 1#00

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puit 3cc 3 2400

?/1+/2014 Tn.-"us *eftria&$ne In% 2 10800

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puit 10 cc 3 3B00

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puit 3 cc 2 1#00

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-ll$purin$l 10 2000

fur$semi tab 10 2000

Tn. aifuin I *at! 20 1 #B00


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puit 10 cc 2 2#00

puit 5 cc 1 1000

puit 3 cc 3 2400

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Ny. unarti )et$r$lac In% 1 ##00


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Ny. eni *eftria&$ne In% 2 10800

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NyP#ni luc$e& 12 4800

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Ny. ri @a!yuni *ipr$ Inf 2 52800

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Tn. -"us -ntrain In% 3 24000

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c 1# 1 15500

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puit 10cc 2 2#00

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Ny. ri @ *ipr$ Inf 2 52800

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Ny. ri @ *ipr$ Inf 2 52800

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puit 10cc 5 #500

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puit 10cc 2 2#00

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Ny. -ni) puit 10 cc 1 1300

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puit 10 cc 3 3B00

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spuit 5c 3 3000

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Nn. iti Ranitiin in% 3 11400

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puit 10 cc 1 1300



puit 3 cc 5 4000

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puit 10 cc 4 5200

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puit 5 cc 1 1000

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puit 10cc 3 3B00

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Tn (ast$eri I 20 1 #B00


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puit 5 cc 3 3000

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puit 3cc 5 4000

puit 5cc 5 5000

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TANGGAL NAMA PASIEN BPJS NAMA OBAT JMLA;

10/2/2014Ny. LutA -aml$ipin 10 m" 10

10/3/2014 Ny. Ra!ayu limepirie 4 m" 30

10/4/2014 Ny. ?rna (etr$ Tab 3

Ranitiin Tab 4

10/+/2014-n. yafa Ranitiin Tab 310/=/2014Ny unarsi! / u $ste$cal 30

r <am,a! *ipr$ tab 30

10/8/2014 Tn. Nur!ai -ml$ipin 10m" 30

10/10/2014-n. -riAn Ranitiin Tab 3

10/1"/2014Ny :o,iatin Ranitiin Tab 10

Ny -ni I *ipr$ tab 10

Ny. 7ani +$mperi$ne syr 1

10/14/2014Ny. (aria *efar$&il *aps 20

r. -li -sam Trane& Tab 20

Tn. -inur *ipr$ tab 22

10/1/2014Ny. ari ?vi *ipr$ tab 10

Tn S#-#r *efar$&il *aps 10

Ny.Lastri iv 20 1

)et$r$lac in% 3

neele 25 1

10/1#/2014 -n. ;ae) +$mperi$ne syr 1

Ny. ri L I *at! 20 2

Infuset biasa 1

10/20/2014 Ny. unarti *efar$&il *aps 10

10/21/2014 N> S&tarni -ml$ipin 10m" 30

Ny.Ina! Ranitiin Tab =

N> Ma(ardini limepirie 4 m" 8

Ny Nin" (etf$rmin tab 45

"emAbr$,il 300 15

Tn (uralim limepirie 4 m" 8

(etf$rmin tab 45

Ny ati%a( +ia, 2m" 5

10/28/2014 Ny. u%i Tr$lip 100 30

(etf$rmin tab B0

+ia, 2m" 10

11/1/2014





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